MEDICARE: DR. HOLLY VIRGINIA MACKENNA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	19239	MS
2	2084P0800X	Psychiatry Physician	025358	LA
3	2084P0800X	Psychiatry Physician	2025-02667	NC

General Provider Information

NPI Number	:	1487668976
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HOLLY VIRGINIA MACKENNA M.D.

Provider Business Mailing Address
First Line	:	PO BOX 640
Second Line	:
City	:	ROANOKE RAPIDS
State	:	NC
Zip	:	27870-0640
Country	:	US
Telephone Number	:	252-536-5844
Fax Number	:	252-519-0154

Provider Business Practice Location Address
First Line	:	2066 NC HIGHWAY 125
Second Line	:
City	:	ROANOKE RAPIDS
State	:	NC
Zip	:	27870-9436
Country	:	US
Telephone Number	:	252-536-5000
Fax Number	:	252-536-2258

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/28/2006
Last Update Date	:	09/16/2025

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