Healthcare Provider Details

I. General information

NPI: 1548131626
Provider Name (Legal Business Name): GUSTAVIA RENEE HALL FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2025
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2039 CAMDEN AVE
SAN JOSE CA
95124-2024
US

IV. Provider business mailing address

9642 RIDDLEWOOD LN
HOUSTON TX
77025-5005
US

V. Phone/Fax

Practice location:
  • Phone: 408-854-5566
  • Fax: 844-889-0275
Mailing address:
  • Phone: 832-545-2420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95039723
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number836882
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: