Provider Demographics
NPI:1942465570
Name:HOLLIS, BRENDA D (MSN,FNP)
Entity Type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:D
Last Name:HOLLIS
Suffix:
Gender:F
Credentials:MSN,FNP
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 1209
Mailing Address - Street 2:
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38025-1209
Mailing Address - Country:US
Mailing Address - Phone:731-285-3300
Mailing Address - Fax:731-285-3370
Practice Address - Street 1:1716 PARR AVE
Practice Address - Street 2:SUITE A
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024-2073
Practice Address - Country:US
Practice Address - Phone:731-285-3300
Practice Address - Fax:731-285-3370
Is Sole Proprietor?:No
Enumeration Date:2008-07-23
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO121969363LP2300X
TN5878363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3730286Medicaid
TNQ001325Medicaid