Healthcare Provider Details

I. General information

NPI: 1962182402
Provider Name (Legal Business Name): MORALE VONETTA HOLSTICK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2023
Last Update Date: 08/17/2023
Certification Date: 08/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3330 SATELLITE BLVD
DULUTH GA
30096-5821
US

IV. Provider business mailing address

1110 PEPPER LN
LAWRENCEVILLE GA
30044-7101
US

V. Phone/Fax

Practice location:
  • Phone: 404-551-7978
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License NumberCOSA063639
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: