Provider Demographics
NPI:1881974913
Name:SCRIVNER, HOLLY LYN
Entity type:Individual
Prefix:MS
First Name:HOLLY
Middle Name:LYN
Last Name:SCRIVNER
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 1:1222 GARDEN LN
Mailing Address - Street 2:
Mailing Address - City:GALESBURG
Mailing Address - State:IL
Mailing Address - Zip Code:61401-2127
Mailing Address - Country:US
Mailing Address - Phone:309-368-0877
Mailing Address - Fax:
Practice Address - Street 1:872 W DAYTON ST
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-1503
Practice Address - Country:US
Practice Address - Phone:309-344-3400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-21
Last Update Date:2011-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160005266261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty