Provider Demographics
NPI:1679579866
Name:MCWHORTER, HOLLY JANE (PT)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:JANE
Last Name:MCWHORTER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:JANE
Other - Last Name:YATES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 949
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30162-0949
Mailing Address - Country:US
Mailing Address - Phone:904-261-4664
Mailing Address - Fax:904-261-5852
Practice Address - Street 1:1897 ISLAND WALK WAY STE 5
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-1949
Practice Address - Country:US
Practice Address - Phone:904-261-4664
Practice Address - Fax:904-261-5852
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT005870225100000X
FLPT35702225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA116769Medicare ID - Type UnspecifiedN GA MEDICARE