Provider Demographics
NPI:1619423910
Name:HALL, AUDRA ANISSA (PT)
Entity Type:Individual
Prefix:
First Name:AUDRA
Middle Name:ANISSA
Last Name:HALL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 TURNER LN
Mailing Address - Street 2:
Mailing Address - City:MIDDLESBORO
Mailing Address - State:KY
Mailing Address - Zip Code:40965-8676
Mailing Address - Country:US
Mailing Address - Phone:502-208-2179
Mailing Address - Fax:
Practice Address - Street 1:108 TURNER LANE
Practice Address - Street 2:
Practice Address - City:MIDDLESBORO
Practice Address - State:KY
Practice Address - Zip Code:40965
Practice Address - Country:US
Practice Address - Phone:606-248-0925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-28
Last Update Date:2016-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist