Provider Demographics
NPI:1518067230
Name:HOLAK, MARYBETH (ARNP)
Entity Type:Individual
Prefix:MS
First Name:MARYBETH
Middle Name:
Last Name:HOLAK
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 COLUMBUS AVENUE
Mailing Address - Street 2:CREDENTIALING SPECIALIST
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06519-1233
Mailing Address - Country:US
Mailing Address - Phone:203-503-3000
Mailing Address - Fax:203-503-6515
Practice Address - Street 1:428 COLUMBUS AVENUE
Practice Address - Street 2:DERMATOLOGY
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1233
Practice Address - Country:US
Practice Address - Phone:203-503-3000
Practice Address - Fax:203-503-3224
Is Sole Proprietor?:No
Enumeration Date:2006-09-23
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6944363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHP61979OtherANTHEM BCBS
CT008075168Medicaid
NHP00067536OtherRAILROAD MEDICARE
NHNP3821Medicare ID - Type Unspecified