Provider Demographics
NPI:1245855204
Name:WILLIS, HOLLY (RN)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 WILLIVEE DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-4750
Mailing Address - Country:US
Mailing Address - Phone:678-699-8630
Mailing Address - Fax:
Practice Address - Street 1:50 GLENLAKE PKWY STE 120
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-7270
Practice Address - Country:US
Practice Address - Phone:800-736-3739
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-15
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024181340363LP0808X
FLAPRN11012845363LP0808X
CA95021595363LP0808X
CO95021595363LP0808X
GARN211263363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health