Provider Demographics
NPI:1851645469
Name:SHIRLEY, HOLLY HARLOW (NP)
Entity Type:Individual
Prefix:MRS
First Name:HOLLY
Middle Name:HARLOW
Last Name:SHIRLEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MISS
Other - First Name:HOLLY
Other - Middle Name:CANDACE
Other - Last Name:HARLOW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2401 S CENTER ST
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-5401
Mailing Address - Country:US
Mailing Address - Phone:618-344-3046
Mailing Address - Fax:618-344-5284
Practice Address - Street 1:2401 S CENTER ST
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-5401
Practice Address - Country:US
Practice Address - Phone:618-344-3046
Practice Address - Fax:618-344-5284
Is Sole Proprietor?:No
Enumeration Date:2012-11-05
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041457619163W00000X
IL209016796363L00000X
VA0024170108363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner