Provider Demographics
NPI:1750438214
Name:HUSTED, HOLLY (NP)
Entity type:Individual
Prefix:MS
First Name:HOLLY
Middle Name:
Last Name:HUSTED
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 HAZEN ST STE C
Mailing Address - Street 2:
Mailing Address - City:PAW PAW
Mailing Address - State:MI
Mailing Address - Zip Code:49079-2008
Mailing Address - Country:US
Mailing Address - Phone:269-655-3334
Mailing Address - Fax:269-657-6523
Practice Address - Street 1:803 W ARLINGTON ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:MI
Practice Address - Zip Code:49013-1108
Practice Address - Country:US
Practice Address - Phone:269-427-6810
Practice Address - Fax:269-657-6523
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704199043363LW0102X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1801818752OtherBCBSM - BMG
MI1750438214Medicaid
MIM97850049Medicare PIN
MI1801818752OtherBCBSM - BMG