Healthcare Provider Details

I. General information

NPI: 1487961140
Provider Name (Legal Business Name): HOLLY JOHNSON-RODRIGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2010
Last Update Date: 08/22/2022
Certification Date: 08/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1609 SUMMERALL LN APT 201
CHESAPEAKE VA
23323-5216
US

IV. Provider business mailing address

1609 SUMMERALL LN APT 201
CHESAPEAKE VA
23323-5216
US

V. Phone/Fax

Practice location:
  • Phone: 423-676-4496
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN0000154657
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number0001313938
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: