Provider Demographics
NPI:1114519873
Name:HALL, BRENTON M (CNP)
Entity type:Individual
Prefix:
First Name:BRENTON
Middle Name:M
Last Name:HALL
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:BRENT
Other - Middle Name:M
Other - Last Name:HALL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:27 ST LAWRENCE DR STE 103
Mailing Address - Street 2:
Mailing Address - City:TIFFIN
Mailing Address - State:OH
Mailing Address - Zip Code:44883-8313
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:27 ST LAWRENCE DR STE 103
Practice Address - Street 2:
Practice Address - City:TIFFIN
Practice Address - State:OH
Practice Address - Zip Code:44883-8313
Practice Address - Country:US
Practice Address - Phone:419-448-4622
Practice Address - Fax:419-448-4808
Is Sole Proprietor?:No
Enumeration Date:2021-02-04
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0028349363L00000X
OHAPRN.CNP.0028349363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner