Basic Information
| Provider Information | |||||||||
| NPI: | 1477165751 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOLLINS | ||||||||
| FirstName: | TORI | ||||||||
| MiddleName: | BROOKE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MSN, APRN, FNP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MORTENSON | ||||||||
| OtherFirstName: | TORI | ||||||||
| OtherMiddleName: | BROOKE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1720 NICHOLASVILLE RD STE 702 | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405031489 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592648811 | ||||||||
| FaxNumber: | 8592648822 | ||||||||
| Practice Location | |||||||||
| Address1: | 1720 NICHOLASVILLE RD STE 702 | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405031489 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592648811 | ||||||||
| FaxNumber: | 8592648822 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2020 | ||||||||
| LastUpdateDate: | 02/03/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 3014587 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 7100697230 | 05 | KY | MEDICAID |