Healthcare Provider Details

I. General information

NPI: 1992744239
Provider Name (Legal Business Name): HOLLY WILSON N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 BUENA VISTA CIR
SOUTH HILL VA
23970-1431
US

IV. Provider business mailing address

PO BOX 34936 DEPT 4227
SEATTLE WA
98124-1936
US

V. Phone/Fax

Practice location:
  • Phone: 434-447-3151
  • Fax:
Mailing address:
  • Phone: 888-398-6618
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0024093711
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: