Healthcare Provider Details

I. General information

NPI: 1285627901
Provider Name (Legal Business Name): HOLLY DENISE FITZPATRICK
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/29/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

331 SIJEN AVE
WHITEMAN AFB MO
65305-1269
US

IV. Provider business mailing address

82 NE 1211
KNOB NOSTER MO
65336-2262
US

V. Phone/Fax

Practice location:
  • Phone: 660-687-4341
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801077165
License Number StateMI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier6801077165
Identifier TypeOTHER
Identifier StateMI
Identifier IssuerLICENSE #

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: