Basic Information
| Provider Information | |||||||||
| NPI: | 1225468028 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MITCHELL | ||||||||
| FirstName: | HOLLY | ||||||||
| MiddleName: | WILSON | ||||||||
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| Credential: | RN, CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 JOHNSON FY RD NE | ||||||||
| Address2: | SUITE 800, CENTER 2 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042521137 | ||||||||
| FaxNumber: | 4045069221 | ||||||||
| Practice Location | |||||||||
| Address1: | 220 J L WHITE DR STE 120 | ||||||||
| Address2: | |||||||||
| City: | JASPER | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301434894 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066923539 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2013 | ||||||||
| LastUpdateDate: | 09/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WW0101X | RN162066 | GA | N | Nursing Service Providers | Registered Nurse | Women's Health Care, Ambulatory | 367A00000X | RN162066 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 003143552C | 05 | GA | MEDICAID | 003143552D | 05 | GA | MEDICAID | 003143552A | 05 | GA | MEDICAID | 003143552B | 05 | GA | MEDICAID |