Provider Demographics
NPI:1881857167
Name:GOMEZ-LEVINE, HOLLY LYNN (APRN, CNP)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:LYNN
Last Name:GOMEZ-LEVINE
Suffix:
Gender:F
Credentials:APRN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1702 UNIVERSITY DR S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-4940
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3500 TOWER AVE
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-4491
Practice Address - Country:US
Practice Address - Phone:715-817-7100
Practice Address - Fax:406-457-8992
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-07
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT100926363LP0808X
WI7182-33363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0000371733OtherBLUE CROSS-SHIELD OF MONTANA
MTP01206032 C01340OtherRAILROAD MEDICARE FOR C4MH
MTM011002929Medicare PIN