Provider Demographics
NPI:1972556363
Name:HALL, ANTHONETTE GENE (CNP)
Entity Type:Individual
Prefix:
First Name:ANTHONETTE
Middle Name:GENE
Last Name:HALL
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2608
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88202-2608
Mailing Address - Country:US
Mailing Address - Phone:575-622-6322
Mailing Address - Fax:575-622-6888
Practice Address - Street 1:305 W COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5892
Practice Address - Country:US
Practice Address - Phone:575-622-6322
Practice Address - Fax:575-622-6888
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR19085363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM98461Medicaid
NMS12906Medicare UPIN