Healthcare Provider Details

I. General information

NPI: 1043616618
Provider Name (Legal Business Name): NICOLE A HALL ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2014
Last Update Date: 11/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 CENTRE ST
MILTON MA
02186-3338
US

IV. Provider business mailing address

170 CENTRE ST
MILTON MA
02186-3338
US

V. Phone/Fax

Practice location:
  • Phone: 617-898-2162
  • Fax:
Mailing address:
  • Phone: 617-898-2162
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2013
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: