Provider Demographics
NPI:1578039707
Name:HALL, TINA
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:HALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2253 N FLAMINGO LN
Mailing Address - Street 2:
Mailing Address - City:SCHELLER
Mailing Address - State:IL
Mailing Address - Zip Code:62883-3009
Mailing Address - Country:US
Mailing Address - Phone:618-315-1757
Mailing Address - Fax:
Practice Address - Street 1:4107 S WATER TOWER PL
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6293
Practice Address - Country:US
Practice Address - Phone:618-244-0031
Practice Address - Fax:618-244-0056
Is Sole Proprietor?:No
Enumeration Date:2018-10-15
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.018461363LF0000X
IL041.394076163W00000X
IL209018461207N00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner