Provider Demographics
NPI:1649161720
Name:HALL, LAURA T (CAA)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:T
Last Name:HALL
Suffix:
Gender:F
Credentials:CAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3315 BLACKFOOT TRL S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-3231
Mailing Address - Country:US
Mailing Address - Phone:470-787-9707
Mailing Address - Fax:
Practice Address - Street 1:3315 BLACKFOOT TRL S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-3231
Practice Address - Country:US
Practice Address - Phone:470-787-9707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-15
Last Update Date:2025-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
367H00000X
FL367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant