Healthcare Provider Details

I. General information

NPI: 1245069780
Provider Name (Legal Business Name): HOLLY REYNOLDS HAGY BSN-RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2024
Last Update Date: 08/01/2024
Certification Date: 07/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 DUGGINS DR
MAGDALENA NM
87825
US

IV. Provider business mailing address

PO BOX 204
MAGDALENA NM
87825-0204
US

V. Phone/Fax

Practice location:
  • Phone: 575-854-8030
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License NumberRN-83521
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: