=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710598073
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA RAE HOLLORON PMHNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2020
-----------------------------------------------------
Last Update Date | 12/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2620 CONNERY WAY
-----------------------------------------------------
City | MISSOULA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59808-1325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-880-9213
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2620 CONNERY WAY
-----------------------------------------------------
City | MISSOULA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59808-1325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-880-9213
-----------------------------------------------------
Fax | 949-864-3190
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | NUR-APRN-LIC-160743
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------