Healthcare Provider Details

I. General information

NPI: 1720699226
Provider Name (Legal Business Name): NANCY MARIE HOLLOWELL PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2020
Last Update Date: 10/20/2021
Certification Date: 10/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 JEFFERSON AVE SE
GRAND RAPIDS MI
49503-4502
US

IV. Provider business mailing address

470 9 MILE RD NE
COMSTOCK PARK MI
49321-9685
US

V. Phone/Fax

Practice location:
  • Phone: 616-685-6902
  • Fax: 616-685-8995
Mailing address:
  • Phone: 812-786-4630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10003078A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: