Healthcare Provider Details

I. General information

NPI: 1750451308
Provider Name (Legal Business Name): HOLLY SUZANNE SMITH OTRL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

629 W ELK AVE
ELIZABETHTON TN
37643-2559
US

IV. Provider business mailing address

719 W PINE ST
JOHNSON CITY TN
37604-6513
US

V. Phone/Fax

Practice location:
  • Phone: 423-543-0073
  • Fax:
Mailing address:
  • Phone: 423-967-5326
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License NumberOT0000003042
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: