Healthcare Provider Details

I. General information

NPI: 1801067608
Provider Name (Legal Business Name): HOLLY LYNNETTE JOHNSON MPAS, PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2008
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 KELLIE DR
SMITHFIELD NC
27577-9444
US

IV. Provider business mailing address

PO BOX 5105
BELFAST ME
04915-5100
US

V. Phone/Fax

Practice location:
  • Phone: 919-934-1094
  • Fax: 919-934-9044
Mailing address:
  • Phone: 919-220-5255
  • Fax: 919-220-5255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2020-0099
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number50.002757
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA 2030
License Number StateOK
# 4
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-02473
License Number StateNC
# 5
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberMA057426
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: