1366876120 NPI number — MRS. HOLLY CELESTE CLEMENTS ARNP

Table of content: MRS. HOLLY CELESTE CLEMENTS ARNP (NPI 1366876120)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366876120 NPI number — MRS. HOLLY CELESTE CLEMENTS ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLEMENTS
Provider First Name:
HOLLY
Provider Middle Name:
CELESTE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
ARNP
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:
1366876120
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/03/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3360
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97208-3360
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-747-2455
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
954 ANDERSON DR STE 102
Provider Second Line Business Practice Location Address:
PMG SW WA PRCS ABERDEEN CLINIC
Provider Business Practice Location Address City Name:
ABERDEEN
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98520-1001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-533-6906
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/29/2013

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:  AP60405648 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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