Provider Demographics
NPI:1861643397
Name:HUBBARD, HOLLY LORRAINE (MD)
Entity Type:Individual
Prefix:DR
First Name:HOLLY
Middle Name:LORRAINE
Last Name:HUBBARD
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 1:4495 ATLANTA HWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-6736
Mailing Address - Country:US
Mailing Address - Phone:770-710-0117
Mailing Address - Fax:470-223-4229
Practice Address - Street 1:4495 ATLANTA HWY
Practice Address - Street 2:BUILDING 200
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-6736
Practice Address - Country:US
Practice Address - Phone:770-710-0117
Practice Address - Fax:470-223-4229
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-02
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101246331208000000X
GA64814208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00304545DMedicaid