Provider Demographics
NPI:1063814101
Name:PORTILLO, HOLLY (NP)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:PORTILLO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:894 US HIGHWAY 77
Mailing Address - Street 2:
Mailing Address - City:ROSEBUD
Mailing Address - State:TX
Mailing Address - Zip Code:76570-3325
Mailing Address - Country:US
Mailing Address - Phone:254-721-2563
Mailing Address - Fax:254-583-7829
Practice Address - Street 1:894 US HIGHWAY 77
Practice Address - Street 2:
Practice Address - City:ROSEBUD
Practice Address - State:TX
Practice Address - Zip Code:76570
Practice Address - Country:US
Practice Address - Phone:254-721-2563
Practice Address - Fax:254-583-7829
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-19
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP126462363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health