Provider Demographics
NPI:1275974719
Name:RICHARDSON, HOLLY ROCHELLE (WHNP)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:ROCHELLE
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:WHNP
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:ROCHELLE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10 S TREATY RD
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:OK
Mailing Address - Zip Code:74354-5330
Mailing Address - Country:US
Mailing Address - Phone:918-238-3074
Mailing Address - Fax:918-238-3076
Practice Address - Street 1:10 S TREATY RD
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:OK
Practice Address - Zip Code:74354-5330
Practice Address - Country:US
Practice Address - Phone:918-238-3074
Practice Address - Fax:918-238-3076
Is Sole Proprietor?:No
Enumeration Date:2013-07-12
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013024829363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200621430AMedicaid
OK465592YK6XMedicare PIN