Healthcare Provider Details

I. General information

NPI: 1932571262
Provider Name (Legal Business Name): HOLLY MEDLEN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HOLLY ANN MCBRIDE

II. Dates (important events)

Enumeration Date: 10/26/2015
Last Update Date: 10/02/2024
Certification Date: 10/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 N SILVER ST STE D
PAOLA KS
66071-1498
US

IV. Provider business mailing address

103 N SILVER ST STE D
PAOLA KS
66071-1498
US

V. Phone/Fax

Practice location:
  • Phone: 913-388-3631
  • Fax: 833-449-2017
Mailing address:
  • Phone: 913-388-3631
  • Fax: 833-449-2017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5377008041
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: