Provider Demographics
NPI:1023159514
Name:HALL, VIVIAN MARLENE (MSN, RN, BC, FNP)
Entity type:Individual
Prefix:
First Name:VIVIAN
Middle Name:MARLENE
Last Name:HALL
Suffix:
Gender:F
Credentials:MSN, RN, BC, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 W LOCKLING ST
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:64628-2003
Mailing Address - Country:US
Mailing Address - Phone:660-268-4006
Mailing Address - Fax:660-258-9006
Practice Address - Street 1:624 W LOCKLING ST
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:MO
Practice Address - Zip Code:64628-2003
Practice Address - Country:US
Practice Address - Phone:660-268-4006
Practice Address - Fax:660-258-9006
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO078235363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
012050097Medicare ID - Type Unspecified