Provider Demographics
NPI:1912553892
Name:HALL, KELLY RUTH (NP-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:RUTH
Last Name:HALL
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1680 COMMUNITY BEACH RD
Mailing Address - Street 2:
Mailing Address - City:ODIN
Mailing Address - State:IL
Mailing Address - Zip Code:62870-2100
Mailing Address - Country:US
Mailing Address - Phone:618-322-6680
Mailing Address - Fax:
Practice Address - Street 1:1680 COMMUNITY BEACH RD
Practice Address - Street 2:
Practice Address - City:ODIN
Practice Address - State:IL
Practice Address - Zip Code:62870-2100
Practice Address - Country:US
Practice Address - Phone:618-322-6680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-15
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209019672363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily