Healthcare Provider Details

I. General information

NPI: 1225468028
Provider Name (Legal Business Name): HOLLY WILSON MITCHELL RN, CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2013
Last Update Date: 09/14/2021
Certification Date: 09/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 J L WHITE DR STE 120
JASPER GA
30143-4894
US

IV. Provider business mailing address

1100 JOHNSON FY RD NE SUITE 800, CENTER 2
ATLANTA GA
30342-1709
US

V. Phone/Fax

Practice location:
  • Phone: 706-692-3539
  • Fax:
Mailing address:
  • Phone: 404-252-1137
  • Fax: 404-506-9221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WW0101X
TaxonomyAmbulatory Women's Health Care Registered Nurse
License NumberRN162066
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberRN162066
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: