Provider Demographics
NPI:1326130394
Name:O'BRYAN, HALLIE T (ARNP)
Entity Type:Individual
Prefix:
First Name:HALLIE
Middle Name:T
Last Name:O'BRYAN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 CLINIC DR
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42431-1661
Mailing Address - Country:US
Mailing Address - Phone:270-825-7200
Mailing Address - Fax:
Practice Address - Street 1:500 CLINIC DR
Practice Address - Street 2:
Practice Address - City:HOPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42240-4991
Practice Address - Country:US
Practice Address - Phone:270-707-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3002153363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY2153POtherLICENSE
KY78001856Medicaid
000000044288OtherBCBS PROVIDER NUMBER
KY78001856Medicaid
0375024Medicare PIN
KY2153POtherLICENSE