Healthcare Provider Details

I. General information

NPI: 1770123820
Provider Name (Legal Business Name): JANE HOLLIS DNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2020
Last Update Date: 01/07/2020
Certification Date: 01/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 N CLYDE MORRIS BLVD
DAYTONA BEACH FL
32114-2709
US

IV. Provider business mailing address

2347 KENILWORTH AVE
SOUTH DAYTONA FL
32119-2752
US

V. Phone/Fax

Practice location:
  • Phone: 561-373-8332
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License Number11005270
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number11005270
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: