Provider Demographics
NPI:1982196507
Name:EASON, HOLLI BAILEY (FNP-BC)
Entity Type:Individual
Prefix:
First Name:HOLLI
Middle Name:BAILEY
Last Name:EASON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1524 AD EASON RD
Mailing Address - Street 2:
Mailing Address - City:CLAXTON
Mailing Address - State:GA
Mailing Address - Zip Code:30417-3738
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:213 N MCDONALD ST STE A&B
Practice Address - Street 2:
Practice Address - City:LUDOWICI
Practice Address - State:GA
Practice Address - Zip Code:31316
Practice Address - Country:US
Practice Address - Phone:912-545-9398
Practice Address - Fax:912-545-2747
Is Sole Proprietor?:No
Enumeration Date:2018-05-30
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN116108363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003207281AMedicaid
GARN116108OtherPROVIDER LICENSE