Basic Information
| Provider Information | |||||||||
| NPI: | 1790048023 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | HOLLY | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 602 E 16TH AVE STE B | ||||||||
| Address2: | |||||||||
| City: | CORDELE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310151782 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292719330 | ||||||||
| FaxNumber: | 2292719245 | ||||||||
| Practice Location | |||||||||
| Address1: | 602 E 16TH AVE STE B | ||||||||
| Address2: | |||||||||
| City: | CORDELE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292719330 | ||||||||
| FaxNumber: | 2292719245 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2012 | ||||||||
| LastUpdateDate: | 07/09/2018 | ||||||||
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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 | 363L00000X | RN169913 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 003125321A | 05 | GA | MEDICAID |