Provider Demographics
NPI:1386835353
Name:HOLLY, SANDRA FAYE (MD)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:FAYE
Last Name:HOLLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3550 HIGHWAY 468 W
Mailing Address - Street 2:
Mailing Address - City:WHITFIELD
Mailing Address - State:MS
Mailing Address - Zip Code:39193-5529
Mailing Address - Country:US
Mailing Address - Phone:601-351-8000
Mailing Address - Fax:601-351-8586
Practice Address - Street 1:3550 HIGHWAY 468 W
Practice Address - Street 2:
Practice Address - City:WHITFIELD
Practice Address - State:MS
Practice Address - Zip Code:39193-5529
Practice Address - Country:US
Practice Address - Phone:601-351-8000
Practice Address - Fax:601-351-8586
Is Sole Proprietor?:No
Enumeration Date:2007-08-06
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS077472084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01820022Medicaid
MS01820022Medicaid