Healthcare Provider Details

I. General information

NPI: 1952239774
Provider Name (Legal Business Name): PETRONA D HOLLOWAY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2026
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 CAMINO DEL RIO S STE 102
SAN DIEGO CA
92108-3586
US

IV. Provider business mailing address

404 CAMINO DEL RIO S STE 102
SAN DIEGO CA
92108-3586
US

V. Phone/Fax

Practice location:
  • Phone: 800-316-6314
  • Fax:
Mailing address:
  • Phone: 800-316-6314
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95039138
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: