Healthcare Provider Details

I. General information

NPI: 1811928625
Provider Name (Legal Business Name): HOLLY C LIBERATORE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HOLLY MOSSMAN

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 05/27/2021
Certification Date: 05/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 DELAWARE ST
LONGVIEW WA
98632-2310
US

IV. Provider business mailing address

PO BOX 11510
WESTMINSTER CA
92685-1510
US

V. Phone/Fax

Practice location:
  • Phone: 360-414-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD00042244
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number23705
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: