Provider Demographics
NPI:1194389577
Name:HALL, LISA JO
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:JO
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 1:995 ROSS ST
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-1743
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:995 ROSS ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-1743
Practice Address - Country:US
Practice Address - Phone:614-971-0097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-01
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN280539363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily