Provider Demographics
NPI:1083366397
Name:HENDERSHOT, HOLLY MARIE (APRN)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:MARIE
Last Name:HENDERSHOT
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:613 BROWN ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR
Mailing Address - State:MI
Mailing Address - Zip Code:48079-4891
Mailing Address - Country:US
Mailing Address - Phone:810-887-7858
Mailing Address - Fax:
Practice Address - Street 1:28800 RYAN RD STE 320
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092-4272
Practice Address - Country:US
Practice Address - Phone:877-906-9699
Practice Address - Fax:866-227-7418
Is Sole Proprietor?:No
Enumeration Date:2022-01-19
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704287330163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse