Healthcare Provider Details

I. General information

NPI: 1669745659
Provider Name (Legal Business Name): HOLLY BOYD CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2012
Last Update Date: 07/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20091 PINEVILLE RD
LONG BEACH MS
39560-3208
US

IV. Provider business mailing address

PO BOX 1810
GULFPORT MS
39502-1810
US

V. Phone/Fax

Practice location:
  • Phone: 228-868-3684
  • Fax: 228-868-3795
Mailing address:
  • Phone: 228-868-3684
  • Fax: 228-868-3795

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberR868511
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberA03700
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number826055
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberA810502
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: