Provider Demographics
NPI:1013575612
Name:KREIENKAMP, HOLLY JEAN
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:JEAN
Last Name:KREIENKAMP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:JEAN
Other - Last Name:STOUT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:571 DOTSON RD
Mailing Address - Street 2:
Mailing Address - City:CUBA
Mailing Address - State:MO
Mailing Address - Zip Code:65453-6146
Mailing Address - Country:US
Mailing Address - Phone:573-259-3512
Mailing Address - Fax:573-732-3172
Practice Address - Street 1:571 DOTSON RD
Practice Address - Street 2:
Practice Address - City:CUBA
Practice Address - State:MO
Practice Address - Zip Code:65453-6146
Practice Address - Country:US
Practice Address - Phone:573-259-3512
Practice Address - Fax:573-732-3172
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-30
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO12042347E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347E00000XTransportation ServicesTransportation Broker