1245393131 NPI number — HOLLYS J NIELSEN FNP

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 1245393131 NPI number — HOLLYS J NIELSEN FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NIELSEN
Provider First Name:
HOLLYS
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
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:
1245393131
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/16/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1593 E POLSTON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POST FALLS
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83854-5326
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-262-2498
Provider Business Mailing Address Fax Number:
208-262-7461

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
750 N SYRINGA ST STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POST FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83854-5275
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-262-2600
Provider Business Practice Location Address Fax Number:
208-262-2700
Provider Enumeration Date:
12/19/2006

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: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: NP416A , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1245393131 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: NP416A . This is a "LICENSE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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