Provider Demographics
NPI:1295449072
Name:SMITH, HOLLIS MACKENZIE
Entity type:Individual
Prefix:
First Name:HOLLIS
Middle Name:MACKENZIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 CLEARFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-1815
Mailing Address - Country:US
Mailing Address - Phone:757-457-5100
Mailing Address - Fax:757-961-3696
Practice Address - Street 1:225 CLEARFIELD AVE
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-1815
Practice Address - Country:US
Practice Address - Phone:757-457-5100
Practice Address - Fax:757-961-3696
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-06
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110009333363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant