Provider Demographics
NPI:1144970922
Name:CONQUEST, HALLE AYANA
Entity type:Individual
Prefix:
First Name:HALLE
Middle Name:AYANA
Last Name:CONQUEST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2010 SW BRISBANE ST
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34984-4404
Mailing Address - Country:US
Mailing Address - Phone:772-251-9976
Mailing Address - Fax:
Practice Address - Street 1:8491 S US HIGHWAY 1 STE 15
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-3360
Practice Address - Country:US
Practice Address - Phone:772-251-9976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-25
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA96582225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty