Provider Demographics
NPI:1437523974
Name:HALL, NICOLE MARIE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:HALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:KIRBY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0909
Mailing Address - Country:US
Mailing Address - Phone:502-588-0328
Mailing Address - Fax:502-587-4784
Practice Address - Street 1:530 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1675
Practice Address - Country:US
Practice Address - Phone:502-852-1735
Practice Address - Fax:502-852-6056
Is Sole Proprietor?:No
Enumeration Date:2015-11-20
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1119245163W00000X
KY3009969367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300001149Medicaid
KY7100424210Medicaid