Provider Demographics
NPI:1063996577
Name:HOLLIS, HOLLY (EDD, RN, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:HOLLIS
Suffix:
Gender:F
Credentials:EDD, RN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 N MAIN ST STE A
Mailing Address - Street 2:
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31313-2570
Mailing Address - Country:US
Mailing Address - Phone:912-785-2100
Mailing Address - Fax:844-740-0009
Practice Address - Street 1:508 N MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-2570
Practice Address - Country:US
Practice Address - Phone:912-785-2100
Practice Address - Fax:844-740-0009
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-20
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN1169906363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner