Provider Demographics
NPI:1265984181
Name:HALL, THERESA GALE (APRN)
Entity type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:GALE
Last Name:HALL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2490 S WOODWORTH LOOP STE 250
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-7407
Mailing Address - Country:US
Mailing Address - Phone:907-861-6700
Mailing Address - Fax:
Practice Address - Street 1:2490 S WOODWORTH LOOP STE 250
Practice Address - Street 2:
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645-7407
Practice Address - Country:US
Practice Address - Phone:907-861-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-26
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3010502363LG0600X
AK132563363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1685772Medicaid