Healthcare Provider Details

I. General information

NPI: 1114339520
Provider Name (Legal Business Name): DORIS LYNN HOLLOWAY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2014
Last Update Date: 05/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 N MAIN ST BOX 436
REESEVILLE WI
53579-9662
US

IV. Provider business mailing address

303 N MAIN ST BOX 436
REESEVILLE WI
53579-9662
US

V. Phone/Fax

Practice location:
  • Phone: 920-927-5308
  • Fax:
Mailing address:
  • Phone: 920-927-5308
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number106042
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: