Provider Demographics
NPI:1477208445
Name:RICHARDSON, HOLLY (FNP)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 LAKE COMO CT
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-5810
Mailing Address - Country:US
Mailing Address - Phone:909-654-9156
Mailing Address - Fax:
Practice Address - Street 1:71777 SAN JACINTO DR STE 202
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-4457
Practice Address - Country:US
Practice Address - Phone:888-743-7526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-17
Last Update Date:2022-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95019657363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily