1770891137 NPI number — HOLLY BRYAN GRADY CRNP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770891137 NPI number — HOLLY BRYAN GRADY CRNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRADY
Provider First Name:
HOLLY
Provider Middle Name:
BRYAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BRYAN
Provider Other First Name:
HOLLY
Provider Other Middle Name:
ELISABETH
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1770891137
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/21/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 936934
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31193-6934
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6527 STATE PARK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TRAVELERS REST
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29690-1696
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-610-2108
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/20/2010

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: 363LP0200X , with the licence number:  19474 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: NP3306 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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