Healthcare Provider Details

I. General information

NPI: 1568245934
Provider Name (Legal Business Name): ALISSA HALL FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2023
Last Update Date: 08/17/2023
Certification Date: 08/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 N DAMEN AVE
CHICAGO IL
60622-1967
US

IV. Provider business mailing address

1236 N WOOD ST APT 1
CHICAGO IL
60622-3250
US

V. Phone/Fax

Practice location:
  • Phone: 312-283-5560
  • Fax:
Mailing address:
  • Phone: 760-908-8523
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number20902872
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: