Healthcare Provider Details

I. General information

NPI: 1023075975
Provider Name (Legal Business Name): MARY PAT HOLLER-BIBEL FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 06/12/2020
Certification Date: 06/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

718 OAK ST
GRAND FORKS ND
58201-4460
US

IV. Provider business mailing address

10900 PEARL RD STE C1
STRONGSVILLE OH
44136-3349
US

V. Phone/Fax

Practice location:
  • Phone: 218-230-0070
  • Fax: 800-958-7702
Mailing address:
  • Phone: 440-268-8422
  • Fax: 440-268-8420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP1338690
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number2010011783
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License NumberNUR-APRN-LIC-153741
License Number StateMT
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR26553
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: