Healthcare Provider Details

I. General information

NPI: 1639719032
Provider Name (Legal Business Name): HOLLY PETTEY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2020
Last Update Date: 01/14/2020
Certification Date: 01/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3704 HIGHWAY 72 W
CORINTH MS
38834-8556
US

IV. Provider business mailing address

401 ALCORN DR STE 2C
CORINTH MS
38834-9073
US

V. Phone/Fax

Practice location:
  • Phone: 662-665-8041
  • Fax:
Mailing address:
  • Phone: 662-293-7618
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number829333
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: