Provider Demographics
NPI:1649272691
Name:HALLOCK, VIRGINIA A (NP)
Entity type:Individual
Prefix:MRS
First Name:VIRGINIA
Middle Name:A
Last Name:HALLOCK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 15238
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31416-1938
Mailing Address - Country:US
Mailing Address - Phone:912-354-4813
Mailing Address - Fax:912-354-7569
Practice Address - Street 1:1115 LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404-5502
Practice Address - Country:US
Practice Address - Phone:912-354-4813
Practice Address - Fax:912-354-7569
Is Sole Proprietor?:No
Enumeration Date:2005-06-02
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAR039856363LA2200X
SCR00079381363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00929255AMedicaid
SCNP0564Medicaid
GA50BBDSQMedicare ID - Type UnspecifiedGA MEDICARE
SCP298016720Medicare ID - Type UnspecifiedSC MEDICARE
GA500016574Medicare ID - Type UnspecifiedRR MEDICARE
GA00929255AMedicaid