Provider Demographics
NPI:1720732308
Name:WORTLEY, HOLLY
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:WORTLEY
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 1:520 MEDICAL DR STE 300
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-8925
Mailing Address - Country:US
Mailing Address - Phone:801-292-1422
Mailing Address - Fax:
Practice Address - Street 1:520 MEDICAL DR STE 300
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-8925
Practice Address - Country:US
Practice Address - Phone:801-292-1422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-11
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8297985-4405363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care