Healthcare Provider Details

I. General information

NPI: 1194198135
Provider Name (Legal Business Name): HOLLY KATHRYN HATTAWAY CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HOLLY HEATH

II. Dates (important events)

Enumeration Date: 11/12/2015
Last Update Date: 11/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1719 6TH AVE S
BIRMINGHAM AL
35294-0001
US

IV. Provider business mailing address

1719 6TH AVE S
BIRMINGHAM AL
35294-0001
US

V. Phone/Fax

Practice location:
  • Phone: 205-975-5587
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number1-136564
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: