Healthcare Provider Details

I. General information

NPI: 1639935281
Provider Name (Legal Business Name): SERENITYPASS HOLISTIC HEALTH PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2024
Last Update Date: 12/16/2024
Certification Date: 12/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 N MINE ST
SANDOVAL IL
62882-1103
US

IV. Provider business mailing address

605 N MINE ST
SANDOVAL IL
62882-1103
US

V. Phone/Fax

Practice location:
  • Phone: 618-552-3034
  • Fax:
Mailing address:
  • Phone: 618-552-3034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KELLY HALL
Title or Position: OWNER
Credential: NP
Phone: 937-577-4266