Provider Demographics
NPI:1437720174
Name:THULL, HOLLY (CPNP-PC)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:THULL
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15902 PRINCETON CT
Mailing Address - Street 2:
Mailing Address - City:FRASER
Mailing Address - State:MI
Mailing Address - Zip Code:48026-4745
Mailing Address - Country:US
Mailing Address - Phone:586-871-0485
Mailing Address - Fax:
Practice Address - Street 1:15902 PRINCETON CT
Practice Address - Street 2:
Practice Address - City:FRASER
Practice Address - State:MI
Practice Address - Zip Code:48026-4745
Practice Address - Country:US
Practice Address - Phone:586-871-0485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-04
Last Update Date:2021-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI202019222208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty