Provider Demographics
NPI:1891359139
Name:HOLLY, VINCENT WILLIAM (RN, APRN, CNS)
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:WILLIAM
Last Name:HOLLY
Suffix:
Gender:M
Credentials:RN, APRN, CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8790 N FISH RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47408-9236
Mailing Address - Country:US
Mailing Address - Phone:812-219-2791
Mailing Address - Fax:
Practice Address - Street 1:601 W 2ND ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2317
Practice Address - Country:US
Practice Address - Phone:812-353-5593
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-23
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28133098A364SC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SC0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistCritical Care Medicine