Healthcare Provider Details

I. General information

NPI: 1649515867
Provider Name (Legal Business Name): HOLLY N. FIDDLER P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HOLLY NESTLE

II. Dates (important events)

Enumeration Date: 11/28/2012
Last Update Date: 05/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 MICHIGAN ST NE SUITE 300
GRAND RAPIDS MI
49503-2550
US

IV. Provider business mailing address

1111 LEFFINGWELL AVE NE
GRAND RAPIDS MI
49525-6406
US

V. Phone/Fax

Practice location:
  • Phone: 616-459-7101
  • Fax: 616-459-8425
Mailing address:
  • Phone: 616-459-7101
  • Fax: 616-954-6483

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601006528
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number5601006528
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: