Provider Demographics
NPI:1376091629
Name:HOLLY, DEASA
Entity Type:Individual
Prefix:
First Name:DEASA
Middle Name:
Last Name:HOLLY
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 1:2473 TIMBERCROFT CT
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45239-6614
Mailing Address - Country:US
Mailing Address - Phone:513-680-3371
Mailing Address - Fax:
Practice Address - Street 1:2473 TIMBERCROFT CT
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45239-6614
Practice Address - Country:US
Practice Address - Phone:513-680-3371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-15
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH302F00000X302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization