Provider Demographics
NPI:1265762413
Name:HALL, TINA TERESA (FNP)
Entity type:Individual
Prefix:MRS
First Name:TINA
Middle Name:TERESA
Last Name:HALL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MRS
Other - First Name:TINA
Other - Middle Name:TERESA
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:29080 MARCUS LN
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:CA
Mailing Address - Zip Code:92346-7763
Mailing Address - Country:US
Mailing Address - Phone:909-633-2648
Mailing Address - Fax:
Practice Address - Street 1:29080 MARCUS LN
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:CA
Practice Address - Zip Code:92346-7763
Practice Address - Country:US
Practice Address - Phone:909-633-2648
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-12
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10120363LF0000X
CA415820363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily