Basic Information
| Provider Information | |||||||||
| NPI: | 1518692342 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HOLLY SPRINGS FAMILY MEDICAL LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 130 W VAN DORN AVE | ||||||||
| Address2: | |||||||||
| City: | HOLLY SPRINGS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386352902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6622743212 | ||||||||
| FaxNumber: | 6622743213 | ||||||||
| Practice Location | |||||||||
| Address1: | 130 W VAN DORN AVE | ||||||||
| Address2: | |||||||||
| City: | HOLLY SPRINGS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386352902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6622743212 | ||||||||
| FaxNumber: | 6622743213 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2022 | ||||||||
| LastUpdateDate: | 09/01/2022 | ||||||||
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| AuthorizedOfficialLastName: | WILLIAMS | ||||||||
| AuthorizedOfficialFirstName: | JERRY | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6622743212 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | II | ||||||||
| AuthorizedOfficialCredential: | DNP, FNP-C | ||||||||
| NPICertificationDate: | 09/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 363LF0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.