Provider Demographics
NPI:1669613170
Name:HALL, BEVERLY NUCKOLS (BS)
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:NUCKOLS
Last Name:HALL
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1167 SPRATLIN PARK DR
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-6205
Mailing Address - Country:US
Mailing Address - Phone:423-467-3721
Mailing Address - Fax:423-467-3644
Practice Address - Street 1:318 DONNELLY ST
Practice Address - Street 2:
Practice Address - City:MOUNTAIN CITY
Practice Address - State:TN
Practice Address - Zip Code:37683-1510
Practice Address - Country:US
Practice Address - Phone:423-727-2100
Practice Address - Fax:423-467-3644
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-12
Last Update Date:2018-08-15
Deactivation Date:2018-07-31
Deactivation Code:
Reactivation Date:2018-08-15
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator