=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861114142
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SELINA GRACE HOLLEY APRN, FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2022
-----------------------------------------------------
Last Update Date | 09/14/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 215 S CEDAR LN
-----------------------------------------------------
City | PULASKI
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38478-3502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-363-2511
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 119 TOLLGATE RD
-----------------------------------------------------
City | PULASKI
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38478-3535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-309-7429
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 32514
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------