Provider Demographics
NPI:1033448642
Name:HOLLEY, AMANDA CAROLINE (AUD)
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:CAROLINE
Last Name:HOLLEY
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 400
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38302-0400
Mailing Address - Country:US
Mailing Address - Phone:731-423-8697
Mailing Address - Fax:731-422-5743
Practice Address - Street 1:700 W FOREST AVE
Practice Address - Street 2:STE. 300
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3937
Practice Address - Country:US
Practice Address - Phone:731-422-0340
Practice Address - Fax:731-422-0319
Is Sole Proprietor?:No
Enumeration Date:2009-12-10
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1057A231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1525271Medicaid
TNP01039815Medicare PIN
TN1525271Medicaid