Provider Demographics
NPI:1295912137
Name:HALL, GRADY STANTON (RN)
Entity type:Individual
Prefix:MR
First Name:GRADY
Middle Name:STANTON
Last Name:HALL
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53025 AVENIDA NAVARRO
Mailing Address - Street 2:
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92253-5406
Mailing Address - Country:US
Mailing Address - Phone:760-771-3008
Mailing Address - Fax:
Practice Address - Street 1:53025 AVENIDA NAVARRO
Practice Address - Street 2:
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-5406
Practice Address - Country:US
Practice Address - Phone:760-771-3008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-23
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN 512918163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse