Provider Demographics
NPI:1275166175
Name:BACKE, HOLLY BERRYMAN (CRNP)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:BERRYMAN
Last Name:BACKE
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 DOGWOOD LN SE
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601-5317
Mailing Address - Country:US
Mailing Address - Phone:256-476-2295
Mailing Address - Fax:
Practice Address - Street 1:1216 SOMERVILLE RD SE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601-4335
Practice Address - Country:US
Practice Address - Phone:256-340-0012
Practice Address - Fax:256-340-1408
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-19
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-139307363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner