MEDICARE: MRS. SANDRA FAYE HOLLY MD

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	2084P0800X	Psychiatry Physician	07747	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1386835353
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SANDRA FAYE HOLLY MD

Provider Business Mailing Address
First Line	:	300 N FARISH ST STE C
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39202-3211
Country	:	US
Telephone Number	:	601-212-6479
Fax Number	:	769-572-5697

Provider Business Practice Location Address
First Line	:	6838 W SUNSET BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90028-7008
Country	:	US
Telephone Number	:	323-461-3161
Fax Number	:	323-461-5683

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

Provider Enumeration Date	:	08/06/2007
Last Update Date	:	07/30/2025

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