Healthcare Provider Details

I. General information

NPI: 1568976637
Provider Name (Legal Business Name): HOLLY ANNE SHOEMAKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2017
Last Update Date: 11/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 BELLEFONTE AVE
LOCK HAVEN PA
17745-1907
US

IV. Provider business mailing address

265 RIVERVIEW DR
MOUNT WOLF PA
17347-9540
US

V. Phone/Fax

Practice location:
  • Phone: 717-654-7488
  • Fax:
Mailing address:
  • Phone: 717-654-7488
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier9118772604
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerUNITED HEALTHCARE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: