Healthcare Provider Details

I. General information

NPI: 1083366397
Provider Name (Legal Business Name): HOLLY MARIE HENDERSHOT APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2022
Last Update Date: 11/07/2022
Certification Date: 11/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28800 RYAN RD STE 320
WARREN MI
48092-4272
US

IV. Provider business mailing address

613 BROWN ST
SAINT CLAIR MI
48079-4891
US

V. Phone/Fax

Practice location:
  • Phone: 877-906-9699
  • Fax: 866-227-7418
Mailing address:
  • Phone: 810-887-7858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704287330
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704287330
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: