| Doctor Name: | HOLLY PORTILLO |
| NPI Number: | 1063814101 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | |
| License Number: | AP126462 |
| Business Practice Address: | 1700 Brazos Ave Rockdale, TX - 765672517 |
| Business Phone Number: | 5124464500 |
| Business Fax Number: | |
| Mailing Address: | 1700 Brazos Ave, ROCKDALE |
| State: | TX |
| Postal Code: | 765672517 |
| Phone Number: | 5124464500 |
| Fax Number: | |
| NPI Enumeration Date: | 09/19/2014 |
| NPI Last Update Date: | 09/19/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363LA2200X |
| License Number: | AP126462 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | TX |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Nurse Practitioner |
| Taxonomy Specialization: | Adult Health |
| Taxonomy Definition: | |