Basic Information
| Provider Information | |||||||||
| NPI: | 1033656665 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FARNAM | ||||||||
| FirstName: | HOLLY | ||||||||
| MiddleName: | ROSS | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 410 W POPLAR ST | ||||||||
| Address2: | |||||||||
| City: | WALLA WALLA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 99362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098973320 | ||||||||
| FaxNumber: | 5098975752 | ||||||||
| Practice Location | |||||||||
| Address1: | 410 W POPLAR ST | ||||||||
| Address2: | |||||||||
| City: | WALLA WALLA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 99362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098972100 | ||||||||
| FaxNumber: | 5098975752 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2017 | ||||||||
| LastUpdateDate: | 01/20/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT00007602 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | PT00007602 | 01 | WA | WA STATE DEPARTMENT OF HEALTH | OTHER |