Healthcare Provider Details

I. General information

NPI: 1659701852
Provider Name (Legal Business Name): MARY HOLLAND
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/25/2013
Last Update Date: 11/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

227 W DOMINICK ST
ROME NY
13440-5853
US

IV. Provider business mailing address

227 W DOMINICK ST
ROME NY
13440-5853
US

V. Phone/Fax

Practice location:
  • Phone: 315-336-6230
  • Fax: 315-337-9262
Mailing address:
  • Phone: 315-336-6230
  • Fax: 315-337-9262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number22383279
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: