1164727269 NPI number — TONIA HOLLEY NP

Table of content: TONIA HOLLEY NP (NPI 1164727269)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164727269 NPI number — TONIA HOLLEY NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOLLEY
Provider First Name:
TONIA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164727269
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/16/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 247
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAUREL
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39441-0247
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-425-7550
Provider Business Mailing Address Fax Number:
601-399-6184

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1122 E MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 4
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39350-2348
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-656-1001
Provider Business Practice Location Address Fax Number:
601-656-7555
Provider Enumeration Date:
01/20/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  R823713 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: R823713 . This is a "LICENSE" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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