Healthcare Provider Details

I. General information

NPI: 1215917216
Provider Name (Legal Business Name): HOLLY KRISTINE LEVINE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 10/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 4TH AVE S STUDENT HEALTH SERVICE
SAINT CLOUD MN
56301-4442
US

IV. Provider business mailing address

720 4TH AVE S STUDENT HEALTH SERVICE
SAINT CLOUD MN
56301-4442
US

V. Phone/Fax

Practice location:
  • Phone: 320-308-4856
  • Fax: 320-308-3192
Mailing address:
  • Phone: 320-308-4856
  • Fax: 320-308-3192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number46257
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: