Provider Demographics
NPI:1134311194
Name:DIAL, HOLLY (RN)
Entity Type:Individual
Prefix:MRS
First Name:HOLLY
Middle Name:
Last Name:DIAL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 S 23RD ST
Mailing Address - Street 2:
Mailing Address - City:WORLAND
Mailing Address - State:WY
Mailing Address - Zip Code:82401
Mailing Address - Country:US
Mailing Address - Phone:307-347-6165
Mailing Address - Fax:307-347-6166
Practice Address - Street 1:401 S 23RD ST
Practice Address - Street 2:
Practice Address - City:WORLAND
Practice Address - State:WY
Practice Address - Zip Code:82401
Practice Address - Country:US
Practice Address - Phone:307-347-6165
Practice Address - Fax:307-347-6166
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY24770163W00000X, 163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY106352903Medicaid
WY106352907Medicaid
WY106352900Medicaid
WY106352908Medicaid