Provider Demographics
NPI:1902366495
Name:HALL, MARY LYDIA (AGPCNP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:LYDIA
Last Name:HALL
Suffix:
Gender:F
Credentials:AGPCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 CEDAR HILL DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-3701
Mailing Address - Country:US
Mailing Address - Phone:601-594-6335
Mailing Address - Fax:
Practice Address - Street 1:501 AVALON WAY STE C
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39047-7500
Practice Address - Country:US
Practice Address - Phone:601-573-7012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-21
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903270363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health