Provider Demographics
NPI:1902847163
Name:HALL, PATRICIA DANIELLE (CPNP)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:DANIELLE
Last Name:HALL
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:DANIELLE
Other - Last Name:HALL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CPNP
Mailing Address - Street 1:2500 NORTH STATE STREET
Mailing Address - Street 2:JMM SUITE 2525
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-815-9528
Mailing Address - Fax:601-984-6439
Practice Address - Street 1:12100 HIGHWAY 49
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3063
Practice Address - Country:US
Practice Address - Phone:228-831-1988
Practice Address - Fax:228-831-1978
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR864001363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05802031Medicaid
MS$$$$$$$$$DOtherBCBS
MS$$$$$$$$$COtherBCBS
MS05802031Medicaid
MS$$$$$$$$$AOtherBCBS
MS$$$$$$$$$OtherBCBS
MS$$$$$$$$$EOtherBCBS
MS$$$$$$$$$BOtherBCBS
MS$$$$$$$$$OtherBCBS
MSQ77178Medicare UPIN
MS500002518Medicare PIN