Provider Demographics
NPI:1649869413
Name:WIGGINS, HOLLY GRACE
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:GRACE
Last Name:WIGGINS
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 1:2889 SOLLIE RD APT 416
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36695-5539
Mailing Address - Country:US
Mailing Address - Phone:256-347-9155
Mailing Address - Fax:
Practice Address - Street 1:2889 SOLLIE RD APT 416
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36695-5539
Practice Address - Country:US
Practice Address - Phone:256-347-9155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-15
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS13165390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program