Provider Demographics
NPI:1629142195
Name:DIMEGLIO, HOLLY S (ANP)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:S
Last Name:DIMEGLIO
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 111602
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99511-1602
Mailing Address - Country:US
Mailing Address - Phone:907-644-3968
Mailing Address - Fax:907-644-3969
Practice Address - Street 1:1407 W 31ST AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-3678
Practice Address - Country:US
Practice Address - Phone:907-644-3968
Practice Address - Fax:907-644-3969
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK928163W00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKNP09282Medicaid