Healthcare Provider Details

I. General information

NPI: 1285280313
Provider Name (Legal Business Name): HOLLY MARIE SHORT FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HOLLY MARIE KOWANICK

II. Dates (important events)

Enumeration Date: 08/14/2019
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 N MAIN ST
FUQUAY VARINA NC
27526-8573
US

IV. Provider business mailing address

PO BOX 602195
CHARLOTTE NC
28260-2195
US

V. Phone/Fax

Practice location:
  • Phone: 919-235-6499
  • Fax:
Mailing address:
  • Phone: 919-350-0351
  • Fax: 919-350-7687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5012132
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5012132
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: