Provider Demographics
NPI:1043684756
Name:CHURCHILL, HOLLY
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:CHURCHILL
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 1:725 NE 24TH ST
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-2105
Mailing Address - Country:US
Mailing Address - Phone:971-901-2331
Mailing Address - Fax:
Practice Address - Street 1:625 NE GALLOWAY ST
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-3933
Practice Address - Country:US
Practice Address - Phone:503-434-7523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-18
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201602402RN163WP0808X
MNR 161857-2163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No163WH0200XNursing Service ProvidersRegistered NurseHome Health