Healthcare Provider Details

I. General information

NPI: 1437720174
Provider Name (Legal Business Name): HOLLY THULL CPNP-PC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/04/2021
Last Update Date: 07/04/2021
Certification Date: 05/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15902 PRINCETON CT
FRASER MI
48026-4745
US

IV. Provider business mailing address

15902 PRINCETON CT
FRASER MI
48026-4745
US

V. Phone/Fax

Practice location:
  • Phone: 586-871-0485
  • Fax:
Mailing address:
  • Phone: 586-871-0485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number202019222
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: