Provider Demographics
NPI:1306221023
Name:HOLLOWAY, KAISHA
Entity Type:Individual
Prefix:
First Name:KAISHA
Middle Name:
Last Name:HOLLOWAY
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 1:605 SANDRA DR
Mailing Address - Street 2:
Mailing Address - City:BROWNS MILLS
Mailing Address - State:NJ
Mailing Address - Zip Code:08015-3769
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:605 SANDRA DRIVE
Practice Address - Street 2:
Practice Address - City:BROWNS MILLS
Practice Address - State:NJ
Practice Address - Zip Code:08015
Practice Address - Country:US
Practice Address - Phone:609-379-1705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-23
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJH62824248251912261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center