1588094726 NPI number — HOLLY SMITH HATLEY FNP

Table of content: HOLLY SMITH HATLEY FNP (NPI 1588094726)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588094726 NPI number — HOLLY SMITH HATLEY FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HATLEY
Provider First Name:
HOLLY
Provider Middle Name:
SMITH
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:
SMITH
Provider Other First Name:
HOLLY
Provider Other Middle Name:
DEANNA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
FNP-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1588094726
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/03/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1420 US HWY 52 NORTH, SUITE G
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBEMARLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-982-9877
Provider Business Mailing Address Fax Number:
704-982-9880

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1420 US 52 N STE G
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBEMARLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28001-2622
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-982-9877
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/26/2013

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:  204971 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 5006616 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1588094726 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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