Basic Information
| Provider Information | |||||||||
| NPI: | 1134311194 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIAL | ||||||||
| FirstName: | HOLLY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | R.N. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 401 S 23RD ST | ||||||||
| Address2: | |||||||||
| City: | WORLAND | ||||||||
| State: | WY | ||||||||
| PostalCode: | 82401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073476165 | ||||||||
| FaxNumber: | 3073476166 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 S 23RD ST | ||||||||
| Address2: | |||||||||
| City: | WORLAND | ||||||||
| State: | WY | ||||||||
| PostalCode: | 82401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073476165 | ||||||||
| FaxNumber: | 3073476166 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2007 | ||||||||
| LastUpdateDate: | 02/10/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 24770 | WY | Y | Nursing Service Providers | Registered Nurse | 163WP0808X | 24770 | WY | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 106352903 | 05 | WY | MEDICAID | 106352907 | 05 | WY | MEDICAID | 106352900 | 05 | WY | MEDICAID | 106352908 | 05 | WY | MEDICAID |