Provider Demographics
NPI:1407314297
Name:STATHAM, HOLLY RAE
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:RAE
Last Name:STATHAM
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 1:1302 CHILDRESS ST
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:79095-3626
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1302 CHILDRESS ST
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:TX
Practice Address - Zip Code:79095-3626
Practice Address - Country:US
Practice Address - Phone:806-205-1494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-11
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX346124164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse