Provider Demographics
NPI:1316615123
Name:STALLER, AMBER DARLENE DAVIS
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:DARLENE DAVIS
Last Name:STALLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:792 WOODWAY LN
Mailing Address - Street 2:
Mailing Address - City:BARGERSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46106-8469
Mailing Address - Country:US
Mailing Address - Phone:317-696-7001
Mailing Address - Fax:
Practice Address - Street 1:295 VILLAGE LN
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-2440
Practice Address - Country:US
Practice Address - Phone:317-881-2591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-06
Last Update Date:2021-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32002138A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant