Provider Demographics
NPI:1376369553
Name:HALL, DEIDRA (NP)
Entity type:Individual
Prefix:
First Name:DEIDRA
Middle Name:
Last Name:HALL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8702 SEDGE MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:WONDER LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60097-7604
Mailing Address - Country:US
Mailing Address - Phone:312-399-1725
Mailing Address - Fax:
Practice Address - Street 1:141 S EASTERN AVE
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:IL
Practice Address - Zip Code:60103-4201
Practice Address - Country:US
Practice Address - Phone:312-399-1725
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-03
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.030954363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily