Provider Demographics
NPI:1245317700
Name:HOLLAND, AMY (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:HOLLAND
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
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 157
Mailing Address - Street 2:
Mailing Address - City:ELLINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63638-0157
Mailing Address - Country:US
Mailing Address - Phone:573-663-2313
Mailing Address - Fax:573-663-2322
Practice Address - Street 1:1003 HWY 25 N
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:MO
Practice Address - Zip Code:63825
Practice Address - Country:US
Practice Address - Phone:573-568-3686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0385738363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q51051Medicare UPIN