Provider Demographics
NPI:1750420725
Name:SHIELDS, HOLLY (PT)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:SHIELDS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:628 BURNETT CIR
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:AR
Mailing Address - Zip Code:71753-2186
Mailing Address - Country:US
Mailing Address - Phone:870-901-9854
Mailing Address - Fax:
Practice Address - Street 1:1010 N DUDNEY RD
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:AR
Practice Address - Zip Code:71753-2624
Practice Address - Country:US
Practice Address - Phone:870-234-3488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2661225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist