Healthcare Provider Details

I. General information

NPI: 1962396481
Provider Name (Legal Business Name): MISTY LYNNE HOLACKA FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2025
Last Update Date: 10/08/2025
Certification Date: 10/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1626 30TH AVE
FAIRBANKS AK
99701-7466
US

IV. Provider business mailing address

1626 30TH AVE
FAIRBANKS AK
99701-7466
US

V. Phone/Fax

Practice location:
  • Phone: 907-479-7701
  • Fax:
Mailing address:
  • Phone: 907-479-7701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number244058
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number146031
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: