Provider Demographics
NPI:1114115284
Name:HOLLOWAY, JOANNA RENEA (LPN)
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:RENEA
Last Name:HOLLOWAY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:186 VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14619-2325
Mailing Address - Country:US
Mailing Address - Phone:585-279-0209
Mailing Address - Fax:
Practice Address - Street 1:600 ISLAND COTTAGE RD
Practice Address - Street 2:
Practice Address - City:GREECE
Practice Address - State:NY
Practice Address - Zip Code:14612-2300
Practice Address - Country:US
Practice Address - Phone:585-621-2446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-13
Last Update Date:2007-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY248605-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02418904Medicaid