Provider Demographics
NPI:1639389216
Name:HALL, JILL K (CRNA)
Entity Type:Individual
Prefix:MS
First Name:JILL
Middle Name:K
Last Name:HALL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MS
Other - First Name:JILL
Other - Middle Name:K
Other - Last Name:MOSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:12303 DE PAUL DR
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-2512
Mailing Address - Country:US
Mailing Address - Phone:314-344-7049
Mailing Address - Fax:314-344-7073
Practice Address - Street 1:12303 DE PAUL DR
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2512
Practice Address - Country:US
Practice Address - Phone:314-344-7049
Practice Address - Fax:314-344-7073
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003017892367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOPENDINGMedicaid
MOPENDINGMedicaid