Provider Demographics
NPI:1467663666
Name:LEO, HOLLY LORRAINE (NP)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:LORRAINE
Last Name:LEO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14642 NEWPORT AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-6057
Mailing Address - Country:US
Mailing Address - Phone:714-669-4466
Mailing Address - Fax:
Practice Address - Street 1:14642 NEWPORT AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-6057
Practice Address - Country:US
Practice Address - Phone:714-669-4466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA415786363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily