Provider Demographics
NPI:1518967397
Name:HOLLIS, MARY L (CNM)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:HOLLIS
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:113 MAIN ST
Mailing Address - Street 2:FIRST FLOOR
Mailing Address - City:BROOKVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15825-1212
Mailing Address - Country:US
Mailing Address - Phone:814-849-2233
Mailing Address - Fax:814-849-2780
Practice Address - Street 1:113 MAIN ST
Practice Address - Street 2:FIRST FLOOR
Practice Address - City:BROOKVILLE
Practice Address - State:PA
Practice Address - Zip Code:15825-1212
Practice Address - Country:US
Practice Address - Phone:814-849-2233
Practice Address - Fax:814-849-2780
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-22
Last Update Date:2007-07-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
PAMW008503L367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018355140004Medicaid
PA018546Medicare UPIN