Healthcare Provider Details

I. General information

NPI: 1710034954
Provider Name (Legal Business Name): HOLLY JO HENDERSON MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6996 COUNTY ROAD 326
PALMYRA MO
63461-3119
US

IV. Provider business mailing address

1005 BROADWAY ST
QUINCY IL
62301-2834
US

V. Phone/Fax

Practice location:
  • Phone: 573-769-3710
  • Fax: 573-769-3753
Mailing address:
  • Phone: 217-223-8400
  • Fax: 217-277-3960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2019032288
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: