Provider Demographics
NPI:1205020963
Name:RICHMOND, HOLLY (PA)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:RICHMOND
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:
Other - Last Name:PETTIPHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:30701 BARRINGTON ST STE 150
Mailing Address - Street 2:
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071-5135
Mailing Address - Country:US
Mailing Address - Phone:248-616-1170
Mailing Address - Fax:248-589-9875
Practice Address - Street 1:3535 W 13 MILE RD STE 437
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6770
Practice Address - Country:US
Practice Address - Phone:248-288-2210
Practice Address - Fax:248-589-9875
Is Sole Proprietor?:No
Enumeration Date:2007-09-05
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004383363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N33470Medicare PIN