Basic Information
| Provider Information | |||||||||
| NPI: | 1972649887 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALLING | ||||||||
| FirstName: | GUY | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | NP NURSE PRACTITIONE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12617 OLD STONE DR | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462369317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176521400 | ||||||||
| FaxNumber: | 3173556096 | ||||||||
| Practice Location | |||||||||
| Address1: | 5470 EAST 16TH STREET | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462184861 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173555009 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2007 | ||||||||
| LastUpdateDate: | 10/08/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 71002327A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 100270530A | 05 | IN | MEDICAID | 201086220 | 05 | IN | MEDICAID |