Provider Demographics
NPI:1639884398
Name:KING, HALLIE
Entity type:Individual
Prefix:
First Name:HALLIE
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 W SULLIVAN ST
Mailing Address - Street 2:
Mailing Address - City:OLEAN
Mailing Address - State:NY
Mailing Address - Zip Code:14760-2521
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:515 MAIN ST
Practice Address - Street 2:
Practice Address - City:OLEAN
Practice Address - State:NY
Practice Address - Zip Code:14760-1513
Practice Address - Country:US
Practice Address - Phone:716-373-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-17
Last Update Date:2024-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA146N00000X
NY390200000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program