Basic Information
| Provider Information | |||||||||
| NPI: | 1013145499 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HALL | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ALICE | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3340 PLAYERS CLUB PKWY STE 350 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381258949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9018441590 | ||||||||
| FaxNumber: | 8447522159 | ||||||||
| Practice Location | |||||||||
| Address1: | 9140 HIGHWAY 51 N # SOUTH | ||||||||
| Address2: | |||||||||
| City: | SOUTHAVEN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386711233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6622808222 | ||||||||
| FaxNumber: | 6622805541 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2009 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN0000158536 | TN | N | Nursing Service Providers | Registered Nurse | 367500000X | 14352 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | RN0000158536 | 01 | TN | RN LICENSE | OTHER | 892560 | 01 | MS | CRNA | OTHER |