1689089013 NPI number — HOLLY LYNN NICHOLS M.D.

Table of content: HOLLY LYNN NICHOLS M.D. (NPI 1689089013)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689089013 NPI number — HOLLY LYNN NICHOLS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NICHOLS
Provider First Name:
HOLLY
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KOKINDA
Provider Other First Name:
HOLLY
Provider Other Middle Name:
LYNN
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:
1689089013
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/04/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2301 ERWIN ROAD, BOX 3808
Provider Second Line Business Mailing Address:
DUKE UNIVERSITY HOSPITAL-DEPARTMENT OF RADIOLOGY
Provider Business Mailing Address City Name:
DURHAM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27710
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-684-7419
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2301 ERWIN ROAD, DUKE UNIVERSITY HOSPITAL NORTH
Provider Second Line Business Practice Location Address:
DEPARTMENT OF RADIOLOGY
Provider Business Practice Location Address City Name:
DURHAM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-684-7419
Provider Business Practice Location Address Fax Number:
864-560-7343
Provider Enumeration Date:
06/24/2014

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: 2085R0202X , with the licence number:  ME144887 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: 2019-00460 , 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: 107747200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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