=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255955506
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRISTY J HOLLOWAY AGNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2020
-----------------------------------------------------
Last Update Date | 06/02/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2645 E SOUTHERN AVE
-----------------------------------------------------
City | TEMPE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85282-7649
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-756-6965
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2645 E SOUTHERN AVE
-----------------------------------------------------
City | TEMPE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85282-7649
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-756-6965
-----------------------------------------------------
Fax | 480-757-6852
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Nurse Practitioner
-----------------------------------------------------
License Number | 241797
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------