1326073446 NPI number — HOLLY YEATTS NP

Table of content: HOLLY YEATTS NP (NPI 1326073446)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326073446 NPI number — HOLLY YEATTS NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
YEATTS
Provider First Name:
HOLLY
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:
1326073446
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/06/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 KIRTS BLVD STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TROY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48084-4135
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-434-6169
Provider Business Mailing Address Fax Number:
855-618-6655

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2132 E 3RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAYTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45403-1991
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-528-6850
Provider Business Practice Location Address Fax Number:
937-528-6810
Provider Enumeration Date:
07/11/2006

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: 363LA2100X , with the licence number:  NP07594 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2623316 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com