MEDICARE: HOLLY RENEE NUMMERDOR DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	5826	TN
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1114504545
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HOLLY RENEE NUMMERDOR DO

Provider Business Mailing Address
First Line	:	1021 W OAKLAND AVE STE 310
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37604-2192
Country	:	US
Telephone Number	:	423-952-2111
Fax Number	:

Provider Business Practice Location Address
First Line	:	701 MED TECH PKWY STE 401
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37604-2372
Country	:	US
Telephone Number	:	423-631-0646
Fax Number	:	423-631-0647

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/24/2021
Last Update Date	:	02/04/2026

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Directions to “ HOLLY RENEE NUMMERDOR DO” Practice Location

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