Provider Demographics
NPI:1053914176
Name:EDSON, HOLLY (NP)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:EDSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4340 REDWOOD HWY STE A-22
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-2121
Mailing Address - Country:US
Mailing Address - Phone:415-472-2343
Mailing Address - Fax:
Practice Address - Street 1:4340 REDWOOD HWY STE A-22
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-2121
Practice Address - Country:US
Practice Address - Phone:415-509-5493
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-19
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95015996363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily