Provider Demographics
NPI:1457994394
Name:HOLLANDSWORTH, NATHANIEL CLAY (IDMT)
Entity Type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:CLAY
Last Name:HOLLANDSWORTH
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 HARRISON DR
Mailing Address - Street 2:
Mailing Address - City:HURLBURT FIELD
Mailing Address - State:FL
Mailing Address - Zip Code:32544-1100
Mailing Address - Country:US
Mailing Address - Phone:850-686-7411
Mailing Address - Fax:
Practice Address - Street 1:517 HARRISON DR
Practice Address - Street 2:
Practice Address - City:HURLBURT FIELD
Practice Address - State:FL
Practice Address - Zip Code:32544-1100
Practice Address - Country:US
Practice Address - Phone:850-686-7411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-23
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians