Healthcare Provider Details

I. General information

NPI: 1972874394
Provider Name (Legal Business Name): HOLLY HULLETT ROY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2012
Last Update Date: 12/29/2025
Certification Date: 12/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14807 MONETA RD STE J
MONETA VA
24121-6449
US

IV. Provider business mailing address

14807 MONETA RD STE J
MONETA VA
24121-6449
US

V. Phone/Fax

Practice location:
  • Phone: 540-703-2682
  • Fax: 540-698-1030
Mailing address:
  • Phone: 540-703-2682
  • Fax: 540-698-1030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110003769
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: