Provider Demographics
NPI:1407430960
Name:HALL, TYREKA DENISE
Entity Type:Individual
Prefix:
First Name:TYREKA
Middle Name:DENISE
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 1:1385 PINNACLE DR APT B
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-8074
Mailing Address - Country:US
Mailing Address - Phone:601-621-6709
Mailing Address - Fax:
Practice Address - Street 1:7000 COBBLE CRK
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-8638
Practice Address - Country:US
Practice Address - Phone:223-666-1403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-11
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS603190850Medicaid