Basic Information
| Provider Information | |||||||||
| NPI: | 1124023643 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOLLISTER | ||||||||
| FirstName: | DEBRA | ||||||||
| MiddleName: | ANN STUMPF | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HOLLISTER | ||||||||
| OtherFirstName: | DEBRA | ||||||||
| OtherMiddleName: | STUMPF | ||||||||
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| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1395 NW 167TH ST | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331695710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5042645142 | ||||||||
| FaxNumber: | 5044552648 | ||||||||
| Practice Location | |||||||||
| Address1: | 3530 HOUMA BLVD STE 300 | ||||||||
| Address2: | |||||||||
| City: | METAIRIE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5042645142 | ||||||||
| FaxNumber: | 5044552648 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2005 | ||||||||
| LastUpdateDate: | 11/22/2019 | ||||||||
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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 | 207Q00000X | 34-00-7136-H | OH | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | DO.000130 | LA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2195851 | 05 | OH | MEDICAID |