Healthcare Provider Details

I. General information

NPI: 1902229180
Provider Name (Legal Business Name): HOLLY RIDGLEY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2014
Last Update Date: 01/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

670 INDIAN TRL RD NW
LILBURN GA
30047-1716
US

IV. Provider business mailing address

2287 MITFORD CT
DACULA GA
30019-2494
US

V. Phone/Fax

Practice location:
  • Phone: 770-925-0088
  • Fax:
Mailing address:
  • Phone: 229-507-9216
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberRN202171
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: