Provider Demographics
NPI:1457069486
Name:PORTIS, HOLLY
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:PORTIS
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 1:1097 200TH ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IA
Mailing Address - Zip Code:50468-8127
Mailing Address - Country:US
Mailing Address - Phone:641-430-1404
Mailing Address - Fax:
Practice Address - Street 1:2600 S EL CAMINO REAL STE 100
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403-2381
Practice Address - Country:US
Practice Address - Phone:650-373-0777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-08
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker