Healthcare Provider Details

I. General information

NPI: 1245238518
Provider Name (Legal Business Name): MARYANN HALL PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 07/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 MILLARD ALLEN DR
LACKEY KY
41643
US

IV. Provider business mailing address

PO BOX 190
LACKEY KY
41643-0190
US

V. Phone/Fax

Practice location:
  • Phone: 606-358-2381
  • Fax: 606-358-2404
Mailing address:
  • Phone: 606-358-2381
  • Fax: 606-358-2404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA781
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: