Provider Demographics
NPI:1073211439
Name:HALL, KELSEY (NP-C)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:HALL
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1394 N MIDTOWN ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-2175
Mailing Address - Country:US
Mailing Address - Phone:208-761-4404
Mailing Address - Fax:
Practice Address - Street 1:1394 N MIDTOWN ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-2175
Practice Address - Country:US
Practice Address - Phone:208-761-4404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-15
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID53667363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner