Healthcare Provider Details

I. General information

NPI: 1639667363
Provider Name (Legal Business Name): HOLLY A LEGG APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2018
Last Update Date: 04/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W ROSS BLVD
DODGE CITY KS
67801-7221
US

IV. Provider business mailing address

200 W ROSS BLVD
DODGE CITY KS
67801-7221
US

V. Phone/Fax

Practice location:
  • Phone: 620-371-7300
  • Fax: 620-371-7304
Mailing address:
  • Phone: 620-371-7300
  • Fax: 620-371-7304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number53-78182-042
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: