Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | 2017017988 | MO |
NPI | 1023510906 |
---|---|
Provider Name | Stephanie R Hollis |
First Address | Ellington, MO 63638-0157 |
Second Address | Ellington, MO 63638-9300 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/03/2018 |
Last Update Date | 06/03/2018 |