Provider Demographics
NPI:1164500476
Name:HOLLEY, MARTHA C (NP)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:C
Last Name:HOLLEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12959 PALMS WEST DR
Mailing Address - Street 2:SUITE 210
Mailing Address - City:LOXAHATCHEE
Mailing Address - State:FL
Mailing Address - Zip Code:33470-4937
Mailing Address - Country:US
Mailing Address - Phone:561-795-3333
Mailing Address - Fax:561-791-3002
Practice Address - Street 1:12959 PALMS WEST DR
Practice Address - Street 2:SUITE 210
Practice Address - City:LOXAHATCHEE
Practice Address - State:FL
Practice Address - Zip Code:33470-4937
Practice Address - Country:US
Practice Address - Phone:561-795-3333
Practice Address - Fax:561-791-3002
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024052901208000000X
FLARNP9269394363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010204011Medicaid