Provider Demographics
NPI:1275875585
Name:CLUCK, HOLLY J (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:HOLLY
Middle Name:J
Last Name:CLUCK
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 BROWN SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-7005
Mailing Address - Country:US
Mailing Address - Phone:334-747-4159
Mailing Address - Fax:
Practice Address - Street 1:2065 E SOUTH BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36116-2458
Practice Address - Country:US
Practice Address - Phone:334-747-7250
Practice Address - Fax:334-747-7270
Is Sole Proprietor?:No
Enumeration Date:2013-03-25
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-106380363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL102I506925Medicare PIN