Provider Demographics
NPI:1578513461
Name:ANDERSEN, HOLLY RENEE (OD)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:RENEE
Last Name:ANDERSEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E JOYCE BLVD
Mailing Address - Street 2:STE. 104
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-6292
Mailing Address - Country:US
Mailing Address - Phone:479-966-4232
Mailing Address - Fax:479-966-4232
Practice Address - Street 1:100 E JOYCE BLVD
Practice Address - Street 2:STE. 104
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-6292
Practice Address - Country:US
Practice Address - Phone:479-966-4232
Practice Address - Fax:479-966-4232
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2533152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR49944Medicare ID - Type Unspecified
ARU92493Medicare UPIN