Provider Demographics
NPI:1134686058
Name:HALL, MIKAELA SHAIN
Entity Type:Individual
Prefix:
First Name:MIKAELA
Middle Name:SHAIN
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 1:5002 EDGECLIFF DR
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76302-4809
Mailing Address - Country:US
Mailing Address - Phone:940-613-9088
Mailing Address - Fax:
Practice Address - Street 1:5002 EDGECLIFF DR
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76302-4809
Practice Address - Country:US
Practice Address - Phone:940-613-9088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-27
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX346643164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse