Healthcare Provider Details

I. General information

NPI: 1518967397
Provider Name (Legal Business Name): MARY L HOLLIS CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/22/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 MAIN ST FIRST FLOOR
BROOKVILLE PA
15825-1212
US

IV. Provider business mailing address

113 MAIN ST FIRST FLOOR
BROOKVILLE PA
15825-1212
US

V. Phone/Fax

Practice location:
  • Phone: 814-849-2233
  • Fax: 814-849-2780
Mailing address:
  • Phone: 814-849-2233
  • Fax: 814-849-2780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberMW008503L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: