Provider Demographics
NPI:1104151729
Name:VANBENCOTEN, HOLLY MARIE O'GRADY (PA)
Entity type:Individual
Prefix:
First Name:HOLLY MARIE
Middle Name:O'GRADY
Last Name:VANBENCOTEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:MARIE
Other - Last Name:O'GRADY VANBENCOTEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:100 KIMEL FOREST DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6074
Mailing Address - Country:US
Mailing Address - Phone:336-716-2255
Mailing Address - Fax:
Practice Address - Street 1:327 ROCK CRUSHER RD
Practice Address - Street 2:
Practice Address - City:ASHEBORO
Practice Address - State:NC
Practice Address - Zip Code:27203-8477
Practice Address - Country:US
Practice Address - Phone:336-636-5546
Practice Address - Fax:336-636-5145
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-15
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-02105363A00000X
NC363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical