Provider Demographics
NPI:1235468679
Name:BREWER, HOLLY (NP)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:BREWER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 W 15TH ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:LIBERAL
Mailing Address - State:KS
Mailing Address - Zip Code:67901-2455
Mailing Address - Country:US
Mailing Address - Phone:620-624-0729
Mailing Address - Fax:620-624-2569
Practice Address - Street 1:315 W 15TH ST
Practice Address - Street 2:SUITE 103
Practice Address - City:LIBERAL
Practice Address - State:KS
Practice Address - Zip Code:67901
Practice Address - Country:US
Practice Address - Phone:620-624-0729
Practice Address - Fax:620-624-2569
Is Sole Proprietor?:No
Enumeration Date:2009-12-14
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK115354363LF0000X
KS75770363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200966390AMedicaid