Provider Demographics
NPI:1417380932
Name:HOLLEY, LEROY KENNETH (LPN)
Entity Type:Individual
Prefix:
First Name:LEROY
Middle Name:KENNETH
Last Name:HOLLEY
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:LEROY
Other - Middle Name:KENNETH
Other - Last Name:POWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CMT
Mailing Address - Street 1:324 N ASH ST
Mailing Address - Street 2:
Mailing Address - City:CORTEZ
Mailing Address - State:CO
Mailing Address - Zip Code:81321-2812
Mailing Address - Country:US
Mailing Address - Phone:970-564-0152
Mailing Address - Fax:
Practice Address - Street 1:324 N ASH ST
Practice Address - Street 2:
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321-2812
Practice Address - Country:US
Practice Address - Phone:970-564-0152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-20
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPN0330637164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse