Healthcare Provider Details

I. General information

NPI: 1124437330
Provider Name (Legal Business Name): WHITNEY J HALL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: WHITNEY J YOUNG PA-C

II. Dates (important events)

Enumeration Date: 08/13/2014
Last Update Date: 09/04/2025
Certification Date: 09/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

139 W HIGHWAY 32
LICKING MO
65542-9898
US

IV. Provider business mailing address

139 W HIGHWAY 32
LICKING MO
65542-9898
US

V. Phone/Fax

Practice location:
  • Phone: 573-674-3011
  • Fax: 573-674-4765
Mailing address:
  • Phone: 573-674-3011
  • Fax: 573-674-4765

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2014031392
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2014027661
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: