Provider Demographics
NPI:1003559592
Name:HALL, MINNICK
Entity Type:Individual
Prefix:
First Name:MINNICK
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 1:36 BELL RD
Mailing Address - Street 2:
Mailing Address - City:CHAZY
Mailing Address - State:NY
Mailing Address - Zip Code:12921-2261
Mailing Address - Country:US
Mailing Address - Phone:518-420-2603
Mailing Address - Fax:
Practice Address - Street 1:36 BELL RD
Practice Address - Street 2:
Practice Address - City:CHAZY
Practice Address - State:NY
Practice Address - Zip Code:12921-2261
Practice Address - Country:US
Practice Address - Phone:518-420-2603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-14
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1816198174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty