Healthcare Provider Details

I. General information

NPI: 1649648940
Provider Name (Legal Business Name): LACIE BETH HALL CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2015
Last Update Date: 09/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

817 VOLVO PKWY
CHESAPEAKE VA
23320-2855
US

IV. Provider business mailing address

817 VOLVO PKWY
CHESAPEAKE VA
23320-2855
US

V. Phone/Fax

Practice location:
  • Phone: 757-668-4630
  • Fax:
Mailing address:
  • Phone: 757-668-4630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number0024172027
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: