Provider Demographics
NPI:1801193206
Name:HALL, JAMIE GAYLE (CRNA)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:GAYLE
Last Name:HALL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:GAYLE
Other - Last Name:MILLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1239 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-3175
Mailing Address - Country:US
Mailing Address - Phone:618-457-5200
Mailing Address - Fax:
Practice Address - Street 1:201 S 14TH ST
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-3631
Practice Address - Country:US
Practice Address - Phone:618-942-2171
Practice Address - Fax:618-351-4919
Is Sole Proprietor?:No
Enumeration Date:2011-02-21
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041365702163W00000X
IL209008660367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL214881OtherNGS GROUP PTAN