Provider Demographics
NPI:1063634095
Name:FALL, HOLLY (NP)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:FALL
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 1:1747 HERRIN ST
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90278-2827
Mailing Address - Country:US
Mailing Address - Phone:310-379-9592
Mailing Address - Fax:
Practice Address - Street 1:16007 CRENSHAW BLVD
Practice Address - Street 2:STUDENT HEALTH SERVICES
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90506-0001
Practice Address - Country:US
Practice Address - Phone:310-660-6417
Practice Address - Fax:310-660-3828
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA293822363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health