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General NPI Number Information
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NPI Number | 1538878053
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Entity Type | Individual
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Provider Name | HOLLY REBECCA ETHEREDGE APRN
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Gender | Female
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Dates
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Enumeration Date | 11/23/2022
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Last Update Date | 01/17/2023
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Provider Practice Location Address
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Address Line | 700 E MARSHALL AVE
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City | LONGVIEW
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State | TX
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Zip | 75601-5580
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Country | US
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Telephone | 903-315-1500
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Fax |
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Provider Business Mailing Address
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Address Line | 3546 FM 959
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City | BECKVILLE
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State | TX
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Zip | 75631-6883
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Country | US
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Telephone | 936-645-8598
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LA2100X
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Taxonomy Name | Acute Care Nurse Practitioner
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License Number | 1099410
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 1099410
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License Number State | TX
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