Provider Demographics
NPI:1003303389
Name:ACKERMANN, HOLLY (FNP)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:ACKERMANN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 955534
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-2551
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1153 E GANNON DR
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-2611
Practice Address - Country:US
Practice Address - Phone:636-282-0380
Practice Address - Fax:636-282-0384
Is Sole Proprietor?:No
Enumeration Date:2018-04-22
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018010406207RR0500X, 363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2018010406OtherMO STATE LICENSE