Provider Demographics
NPI:1013145499
Name:HALL, MARY ALICE (CRNA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ALICE
Last Name:HALL
Suffix:
Gender:F
Credentials:CRNA
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Other - First Name:
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Mailing Address - Street 1:3340 PLAYERS CLUB PKWY STE 350
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38125-8949
Mailing Address - Country:US
Mailing Address - Phone:901-844-1590
Mailing Address - Fax:844-752-2159
Practice Address - Street 1:9140 HIGHWAY 51 N # SOUTH
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-1233
Practice Address - Country:US
Practice Address - Phone:662-280-8222
Practice Address - Fax:662-280-5541
Is Sole Proprietor?:No
Enumeration Date:2009-06-24
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN0000158536163W00000X
TN14352367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNRN0000158536OtherRN LICENSE
MS892560OtherCRNA