Provider Demographics
NPI:1194864405
Name:HOLSOMBACK, MARTHA JO (WHNP)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:JO
Last Name:HOLSOMBACK
Suffix:
Gender:F
Credentials:WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7545 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-1615
Mailing Address - Country:US
Mailing Address - Phone:770-928-0133
Mailing Address - Fax:770-928-1663
Practice Address - Street 1:7545 MAIN ST
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-1615
Practice Address - Country:US
Practice Address - Phone:770-928-0133
Practice Address - Fax:770-928-1663
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN046903363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00520341BMedicaid