Provider Demographics
NPI:1245224047
Name:HALL, MYLINDA ANN (FNP)
Entity Type:Individual
Prefix:
First Name:MYLINDA
Middle Name:ANN
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 1:911 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:FL
Mailing Address - Zip Code:32693-3239
Mailing Address - Country:US
Mailing Address - Phone:352-463-2374
Mailing Address - Fax:352-463-2726
Practice Address - Street 1:109 S.W. SAVANNAH AVE.
Practice Address - Street 2:
Practice Address - City:BRANFORD
Practice Address - State:FL
Practice Address - Zip Code:32008-2744
Practice Address - Country:US
Practice Address - Phone:386-935-3090
Practice Address - Fax:352-463-2726
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004002791163W00000X, 363LF0000X
ARA01611363LF0000X
FLARNP9356147363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000082410Medicare ID - Type UnspecifiedMISSOURI MEDICARE
MOP17768Medicare UPIN