Healthcare Provider Details

I. General information

NPI: 1750270500
Provider Name (Legal Business Name): FAY MARSHELLE WALLER FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2025
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 FERRY ST FL 1
LAFAYETTE IN
47901-1143
US

IV. Provider business mailing address

8924 ARABELLA LN
SEMINOLE FL
33777-2649
US

V. Phone/Fax

Practice location:
  • Phone: 800-991-7630
  • Fax: 800-921-1799
Mailing address:
  • Phone: 800-991-7630
  • Fax: 800-921-1799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71016908A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: