Provider Demographics
NPI:1245836634
Name:HALL, MARISSA GRACE (LPN)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:GRACE
Last Name:HALL
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:MARISSA
Other - Middle Name:GRACE
Other - Last Name:ADAMS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:1515 NE LAWRIE TATUM RD
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73507-3099
Mailing Address - Country:US
Mailing Address - Phone:580-354-5000
Mailing Address - Fax:
Practice Address - Street 1:1515 NE LAWRIE TATUM RD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73507-3099
Practice Address - Country:US
Practice Address - Phone:580-354-5404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-10
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK211753163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse