Provider Demographics
NPI:1629616099
Name:HALL, BREYANNA
Entity Type:Individual
Prefix:
First Name:BREYANNA
Middle Name:
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 1:6771 STANHOPE WAY
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-9570
Mailing Address - Country:US
Mailing Address - Phone:317-209-7564
Mailing Address - Fax:317-377-4139
Practice Address - Street 1:6771 STANHOPE WAY
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-9570
Practice Address - Country:US
Practice Address - Phone:317-209-7564
Practice Address - Fax:317-377-4139
Is Sole Proprietor?:No
Enumeration Date:2019-12-17
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300031995Medicaid