Provider Demographics
NPI:1063019891
Name:HOLLEY, CASEY
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:HOLLEY
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 1:2944 JACKSON TWP RD 186 SW
Mailing Address - Street 2:
Mailing Address - City:JUNCTION CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43748
Mailing Address - Country:US
Mailing Address - Phone:740-215-4624
Mailing Address - Fax:
Practice Address - Street 1:1345 FULLER CT
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130-7852
Practice Address - Country:US
Practice Address - Phone:740-215-4624
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-05
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH6401946Medicaid