Healthcare Provider Details

I. General information

NPI: 1538547609
Provider Name (Legal Business Name): HOLLY NICOLE BOTTOMS A-GNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2015
Last Update Date: 10/16/2023
Certification Date: 10/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 MEMORIAL DR
DALTON GA
30720-2529
US

IV. Provider business mailing address

1504 BROADRICK DR
DALTON GA
30720-3011
US

V. Phone/Fax

Practice location:
  • Phone: 706-272-6000
  • Fax: 706-278-0087
Mailing address:
  • Phone: 62-786-4037
  • Fax: 706-278-0087

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberGAA-NP001110
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: