Provider Demographics
NPI:1336482082
Name:BOOE, HOLLI
Entity Type:Individual
Prefix:
First Name:HOLLI
Middle Name:
Last Name:BOOE
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 1:2431 S LOOP 289
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79423-1519
Mailing Address - Country:US
Mailing Address - Phone:806-771-8008
Mailing Address - Fax:806-771-8009
Practice Address - Street 1:2431 S LOOP 289
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79423-1519
Practice Address - Country:US
Practice Address - Phone:806-771-8008
Practice Address - Fax:806-771-8009
Is Sole Proprietor?:No
Enumeration Date:2013-04-01
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT82665133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8DS362OtherBLUE CROSS BLUE SHIELD
TX321582401Medicaid
TX321582401Medicaid