Basic Information
| Provider Information | |||||||||
| NPI: | 1386777878 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLYARD | ||||||||
| FirstName: | HOLLY | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 NORTH MAIN | ||||||||
| Address2: | |||||||||
| City: | LOVINGTON | ||||||||
| State: | NM | ||||||||
| PostalCode: | 882602830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5753966611 | ||||||||
| FaxNumber: | 5753961454 | ||||||||
| Practice Location | |||||||||
| Address1: | 605 WEST TAYLOR | ||||||||
| Address2: | |||||||||
| City: | LOVINGTON | ||||||||
| State: | NM | ||||||||
| PostalCode: | 88260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5757390062 | ||||||||
| FaxNumber: | 5753961454 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2007 | ||||||||
| LastUpdateDate: | 08/17/2017 | ||||||||
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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 | 363LF0000X | R26153 | NM | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | CNP00494 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 99177528 | 05 | NM | MEDICAID | 515063YNGG | 01 | NM | PTAN | OTHER |