Healthcare Provider Details

I. General information

NPI: 1295515054
Provider Name (Legal Business Name): STEPHANIE GAIL HALL CCA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2023
Last Update Date: 03/12/2025
Certification Date: 03/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11849 NANSEMOND PL
LOUISVILLE KY
40245-1763
US

IV. Provider business mailing address

11849 NANSEMOND PL
LOUISVILLE KY
40245-1763
US

V. Phone/Fax

Practice location:
  • Phone: 502-774-0671
  • Fax: 502-632-0659
Mailing address:
  • Phone: 502-650-2650
  • Fax: 502-632-0659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247000000X
TaxonomyHealth Information Technician
License Number225856
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: