Provider Demographics
NPI:1417423914
Name:MATHEWS, HOLLY L (CPNP-PC)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:L
Last Name:MATHEWS
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:L
Other - Last Name:KOSIR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CPNP-PC
Mailing Address - Street 1:1410 CRAIN HWY N STE 5A
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6565 N CHARLES ST STE 306
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21204-5804
Practice Address - Country:US
Practice Address - Phone:443-849-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-23
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR235523363LP0200X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD222797500Medicaid