Healthcare Provider Details

I. General information

NPI: 1992318489
Provider Name (Legal Business Name): HOLLIE MARIE MIMS FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2020
Last Update Date: 08/25/2020
Certification Date: 08/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 TEXAN TRL
CORPUS CHRISTI TX
78411-2547
US

IV. Provider business mailing address

161 WHISTLERS COVE RD
ROCKPORT TX
78382-4329
US

V. Phone/Fax

Practice location:
  • Phone: 361-854-0811
  • Fax:
Mailing address:
  • Phone: 706-631-0046
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1010839
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: