Provider Demographics
NPI:1144878588
Name:STEWART, HOLLY DAE
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:DAE
Last Name:STEWART
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3655 CROSSINGS DR
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-7101
Mailing Address - Country:US
Mailing Address - Phone:928-778-9250
Mailing Address - Fax:928-778-2306
Practice Address - Street 1:3655 CROSSINGS DR
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-7101
Practice Address - Country:US
Practice Address - Phone:928-778-9250
Practice Address - Fax:928-778-2306
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-28
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8762363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant