Healthcare Provider Details

I. General information

NPI: 1063746345
Provider Name (Legal Business Name): VICKEY M HALL FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2009
Last Update Date: 09/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1771 CURTIS DR
IUKA MS
38852-1001
US

IV. Provider business mailing address

1771 CURTIS DR
IUKA MS
38852-1001
US

V. Phone/Fax

Practice location:
  • Phone: 662-423-6016
  • Fax:
Mailing address:
  • Phone: 662-423-6016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR824545
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: