Provider Demographics
NPI:1093284440
Name:HALL, TYECHIA LEWIS (FNP)
Entity Type:Individual
Prefix:MRS
First Name:TYECHIA
Middle Name:LEWIS
Last Name:HALL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13988 GA HIGHWAY 90 E
Mailing Address - Street 2:
Mailing Address - City:MONTEZUMA
Mailing Address - State:GA
Mailing Address - Zip Code:31063-3004
Mailing Address - Country:US
Mailing Address - Phone:478-957-0386
Mailing Address - Fax:
Practice Address - Street 1:811 N 4TH ST
Practice Address - Street 2:
Practice Address - City:CORDELE
Practice Address - State:GA
Practice Address - Zip Code:31015-3219
Practice Address - Country:US
Practice Address - Phone:229-273-5575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-15
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN206917208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics