Provider Demographics
NPI:1134598881
Name:HALL, AMANDA NICOLE (CRNA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:NICOLE
Last Name:HALL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:NICOLE
Other - Last Name:STIDHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1108 ROSS CLARK CIRCLE
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-2911
Mailing Address - Country:US
Mailing Address - Phone:334-793-8111
Mailing Address - Fax:
Practice Address - Street 1:1108 ROSS CLARK CIRCLE
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-2911
Practice Address - Country:US
Practice Address - Phone:334-793-8111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-23
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX802889367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered