Provider Demographics
NPI:1073167078
Name:HOLBERT, MARY BETH
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BETH
Last Name:HOLBERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 LEGION AVE
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:TN
Mailing Address - Zip Code:37091-2898
Mailing Address - Country:US
Mailing Address - Phone:931-359-1551
Mailing Address - Fax:
Practice Address - Street 1:206 LEGION AVE
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:TN
Practice Address - Zip Code:37091-2898
Practice Address - Country:US
Practice Address - Phone:931-359-1551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-29
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN92363164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse