Provider Demographics
NPI:1851061956
Name:HALL, LARRY D JR
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:D
Last Name:HALL
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5632 DOVE DR
Mailing Address - Street 2:
Mailing Address - City:PACE
Mailing Address - State:FL
Mailing Address - Zip Code:32571-9569
Mailing Address - Country:US
Mailing Address - Phone:850-529-9135
Mailing Address - Fax:
Practice Address - Street 1:6002 BERRYHILL RD
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32570-5062
Practice Address - Country:US
Practice Address - Phone:850-626-5150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-20
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11015472364SA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2100XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAcute Care