Provider Demographics
NPI:1194941450
Name:BLACK, HOLLY BRONSON (CPNP)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:BRONSON
Last Name:BLACK
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 JEFFERSON ST STE 404
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70501-6991
Mailing Address - Country:US
Mailing Address - Phone:281-346-0018
Mailing Address - Fax:281-346-0913
Practice Address - Street 1:7629 TIKI DR
Practice Address - Street 2:
Practice Address - City:FULSHEAR
Practice Address - State:TX
Practice Address - Zip Code:77441-1548
Practice Address - Country:US
Practice Address - Phone:281-398-7353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX628292363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics