Provider Demographics
NPI:1477176642
Name:HALL, STEPHANIE LEAH (RN, CCRN)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LEAH
Last Name:HALL
Suffix:
Gender:F
Credentials:RN, CCRN
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:LEAH
Other - Last Name:PETROSKEY HALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RT(R), PET, CNMT
Mailing Address - Street 1:6108 MOSSY OAK DR E
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-8807
Mailing Address - Country:US
Mailing Address - Phone:662-660-8981
Mailing Address - Fax:
Practice Address - Street 1:400 VETERANS AVE
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531-2410
Practice Address - Country:US
Practice Address - Phone:662-523-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-22
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSMS-903626163WC0200X
TN024917207UN0902X
TN3630702471C3402X
TNS-82650247200000X
MS903626163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
No207UN0902XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Imaging & Therapy
No2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiography
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other