Healthcare Provider Details

I. General information

NPI: 1487619078
Provider Name (Legal Business Name): HOLLY A WARD MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 01/22/2021
Certification Date: 01/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 10TH AVE
SHALIMAR FL
32579-1304
US

IV. Provider business mailing address

11 10TH AVE
SHALIMAR FL
32579-1304
US

V. Phone/Fax

Practice location:
  • Phone: 850-651-3376
  • Fax: 850-651-3372
Mailing address:
  • Phone: 850-651-3376
  • Fax: 850-651-3372

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberME82532
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: