Provider Demographics
NPI:1922559962
Name:HALL, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:HALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 WARDS CORNER RD STE 200
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:45140-6966
Mailing Address - Country:US
Mailing Address - Phone:513-707-4041
Mailing Address - Fax:513-576-1020
Practice Address - Street 1:6535 SNIDER RD
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:OH
Practice Address - Zip Code:45140-9588
Practice Address - Country:US
Practice Address - Phone:513-575-1444
Practice Address - Fax:513-575-1451
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-14
Last Update Date:2021-03-25
Deactivation Date:2018-03-01
Deactivation Code:
Reactivation Date:2018-05-02
Provider Licenses
StateLicense IDTaxonomies
OH390200000X
OHAPRN.CNP.022401363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0280759Medicaid