Healthcare Provider Details

I. General information

NPI: 1376979799
Provider Name (Legal Business Name): HOLLY ROGERS GAINES ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2013
Last Update Date: 02/22/2021
Certification Date: 02/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 MEDICAL LN
CONWAY AR
72034-4912
US

IV. Provider business mailing address

PO BOX 20430
WHITE HALL AR
71612-0430
US

V. Phone/Fax

Practice location:
  • Phone: 501-224-5200
  • Fax:
Mailing address:
  • Phone: 501-661-9191
  • Fax: 501-661-1991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberA003851
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: