Provider Demographics
NPI:1770201808
Name:ALDRICH, HOLLY REBECCA
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:REBECCA
Last Name:ALDRICH
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 1:5647 NW LORNA CT
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-3904
Mailing Address - Country:US
Mailing Address - Phone:772-323-6670
Mailing Address - Fax:
Practice Address - Street 1:380 SW PRIMA VISTA BLVD
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983-1984
Practice Address - Country:US
Practice Address - Phone:772-785-8989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-15
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11021383363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily