=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891359139
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VINCENT WILLIAM HOLLY RN, APRN, CNS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2019
-----------------------------------------------------
Last Update Date | 04/23/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 601 W 2ND ST
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47403-2317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-353-5593
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8790 N FISH RD
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47408-9236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-219-2791
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 364SC0200X
-----------------------------------------------------
Taxonomy Name | Critical Care Medicine Clinical Nurse Specialist
-----------------------------------------------------
License Number | 28133098A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------