Provider Demographics
NPI:1194041152
Name:HALL, KELLI DANIELLE GRIM (MD)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:DANIELLE GRIM
Last Name:HALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:DANIELLE
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:10310 THE GROVE BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70836-6455
Mailing Address - Country:US
Mailing Address - Phone:225-761-5200
Mailing Address - Fax:225-761-5549
Practice Address - Street 1:10310 THE GROVE BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70836-6455
Practice Address - Country:US
Practice Address - Phone:225-761-5470
Practice Address - Fax:225-761-5549
Is Sole Proprietor?:No
Enumeration Date:2010-04-15
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LAMD.206157207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2108158Medicaid
MS02784541Medicaid
LA356135YH3VMedicare PIN