Provider Demographics
NPI:1710598073
Name:HOLLORON, AMANDA RAE (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:RAE
Last Name:HOLLORON
Suffix:
Gender:F
Credentials:PMHNP-BC
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 12
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0012
Mailing Address - Country:US
Mailing Address - Phone:406-327-3362
Mailing Address - Fax:
Practice Address - Street 1:900 N ORANGE ST STE 202
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-2951
Practice Address - Country:US
Practice Address - Phone:406-327-3362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-11
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTNUR-APRN-LIC-160743363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health