Provider Demographics
NPI:1801909916
Name:HALL, ANITA CHARLENE (APRN, PMHNP-BC)
Entity type:Individual
Prefix:MS
First Name:ANITA
Middle Name:CHARLENE
Last Name:HALL
Suffix:
Gender:F
Credentials:APRN, PMHNP-BC
Other - Prefix:MS
Other - First Name:ANITA
Other - Middle Name:CHARLENE
Other - Last Name:FAIRCHILD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN, FNP
Mailing Address - Street 1:8990 LORRAINE RD
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-4176
Mailing Address - Country:US
Mailing Address - Phone:228-331-3310
Mailing Address - Fax:228-284-1608
Practice Address - Street 1:8990 LORRAINE RD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-4176
Practice Address - Country:US
Practice Address - Phone:228-331-3310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR702439363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05250546Medicaid
AL891008760Medicaid
MS512I500246Medicare PIN
MSQ34749Medicare UPIN
MS500001711Medicare ID - Type Unspecified