MEDICARE: JESSICA MARIE HOLLOWAY APRN

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	363LP2300X	Primary Care Nurse Practitioner	79848	KS

General Provider Information

NPI Number	:	1407452212
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA MARIE HOLLOWAY APRN

Provider Business Mailing Address
First Line	:	180 RANGER ST
Second Line	:
City	:	HAYSVILLE
State	:	KS
Zip	:	67060-1510
Country	:	US
Telephone Number	:	316-680-0258
Fax Number	:

Provider Business Practice Location Address
First Line	:	437 CEDAR ST
Second Line	:
City	:	KINGMAN
State	:	KS
Zip	:	67068-1324
Country	:	US
Telephone Number	:	620-553-5040
Fax Number	:

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

Provider Enumeration Date	:	12/07/2020
Last Update Date	:	12/08/2020

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