Provider Demographics
NPI:1760968242
Name:HALL, SHELBY L (LMT)
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:L
Last Name:HALL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4975 E FERNWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-4420
Mailing Address - Country:US
Mailing Address - Phone:907-315-9614
Mailing Address - Fax:
Practice Address - Street 1:360 E INTERNATIONAL AIRPORT RD STE 4
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99518-1217
Practice Address - Country:US
Practice Address - Phone:907-563-7700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-17
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK133045225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty