Provider Demographics
NPI:1689936676
Name:STEGALL, HOLLY L (MD)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:L
Last Name:STEGALL
Suffix:
Gender:F
Credentials:MD
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 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1106 REYNOLDS ST
Practice Address - Street 2:STE 100
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28112-4375
Practice Address - Country:US
Practice Address - Phone:704-289-5443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-14
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2014-01668207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1689936676Medicaid
SC016681Medicaid
NCNCO992BMedicare PIN
NCNCO992CMedicare PIN
NCNCO992AMedicare PIN