Provider Demographics
NPI:1063679389
Name:HALL, COLISSA
Entity Type:Individual
Prefix:
First Name:COLISSA
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 1:215 W GILLESPIE ST
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-3207
Mailing Address - Country:US
Mailing Address - Phone:662-418-5324
Mailing Address - Fax:662-615-6161
Practice Address - Street 1:215 W GILLESPIE ST
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-3207
Practice Address - Country:US
Practice Address - Phone:662-418-5324
Practice Address - Fax:662-615-6161
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-22
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant