Healthcare Provider Details

I. General information

NPI: 1578274569
Provider Name (Legal Business Name): HALLE RAE DENNIS PA-S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2022
Last Update Date: 11/07/2023
Certification Date: 11/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 MEDICAL CENTER BLVD
MARRERO LA
70072-3147
US

IV. Provider business mailing address

361 COTUIT BAY DR
COTUIT MA
02635-2910
US

V. Phone/Fax

Practice location:
  • Phone: 504-349-2410
  • Fax:
Mailing address:
  • Phone: 774-327-0240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number339198
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: