Healthcare Provider Details

I. General information

NPI: 1972051522
Provider Name (Legal Business Name): DANIEL JAMES HOLLOWAY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2016
Last Update Date: 02/27/2023
Certification Date: 02/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 NORTHLAKE AVE STE 207
RIDGELAND MS
39157-1717
US

IV. Provider business mailing address

201 NORTHLAKE AVE STE 207
RIDGELAND MS
39157-1717
US

V. Phone/Fax

Practice location:
  • Phone: 601-366-4696
  • Fax:
Mailing address:
  • Phone: 601-366-4696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number901686
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: