Provider Demographics
NPI:1174831762
Name:CHAMPAGNE, HOLLY (RN)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:CHAMPAGNE
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 1:117 HIGH STREET
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-6401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:117 HIGH ST
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-6401
Practice Address - Country:US
Practice Address - Phone:530-477-1369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-17
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2771364S00000X
CA314108163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist