Healthcare Provider Details

I. General information

NPI: 1265749295
Provider Name (Legal Business Name): HOLLY WAITES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2010
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

594 S 100 W
NEPHI UT
84648-2018
US

IV. Provider business mailing address

594 S 100 W
NEPHI UT
84648-2018
US

V. Phone/Fax

Practice location:
  • Phone: 530-388-8247
  • Fax:
Mailing address:
  • Phone: 530-388-8247
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number8397
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: