Basic Information
| Provider Information | |||||||||
| NPI: | 1457906026 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALZ | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | LEEANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | AGNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WESTFALL | ||||||||
| OtherFirstName: | STEPHANIE | ||||||||
| OtherMiddleName: | LEEANN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | AGNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 720 ESKENAZI AVE | ||||||||
| Address2: | FIFTH THIRD BANK BLDG, 5TH FL | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462025166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178804121 | ||||||||
| FaxNumber: | 3178800343 | ||||||||
| Practice Location | |||||||||
| Address1: | 720 ESKENAZI AVE | ||||||||
| Address2: | FIFTH THIRD BANK BLDG, 5TH FL | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462025166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178804121 | ||||||||
| FaxNumber: | 3178800343 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2019 | ||||||||
| LastUpdateDate: | 11/12/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 28209559A | IN | N | Nursing Service Providers | Registered Nurse | 363LG0600X | 71009394A | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363L00000X | 71009394A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.