Healthcare Provider Details

I. General information

NPI: 1396960951
Provider Name (Legal Business Name): HOLLY E GANNON RNC, NNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 11/19/2020
Certification Date: 11/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 S GRAND BLVD
SAINT LOUIS MO
63104-1003
US

IV. Provider business mailing address

2 AUBURN RIDGE CT
SAINT PETERS MO
63376-6865
US

V. Phone/Fax

Practice location:
  • Phone: 314-268-2700
  • Fax: 314-268-6474
Mailing address:
  • Phone: 636-922-9446
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number106839
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: