MEDICARE: MARY L HOLLIS CNM

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	367A00000X	Advanced Practice Midwife	MW008503L	PA

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	:	1518967397
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY L HOLLIS CNM

Provider Business Mailing Address
First Line	:	113 MAIN ST
Second Line	:	FIRST FLOOR
City	:	BROOKVILLE
State	:	PA
Zip	:	15825-1212
Country	:	US
Telephone Number	:	814-849-2233
Fax Number	:	814-849-2780

Provider Business Practice Location Address
First Line	:	113 MAIN ST
Second Line	:	FIRST FLOOR
City	:	BROOKVILLE
State	:	PA
Zip	:	15825-1212
Country	:	US
Telephone Number	:	814-849-2233
Fax Number	:	814-849-2780

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

Provider Enumeration Date	:	07/22/2005
Last Update Date	:	07/09/2007

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