Provider Demographics
NPI:1477536050
Name:HOLLOWAY, SALLY JO
Entity Type:Individual
Prefix:MS
First Name:SALLY
Middle Name:JO
Last Name:HOLLOWAY
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 1:2070 TEMPLE AVE
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-4221
Mailing Address - Country:US
Mailing Address - Phone:321-453-8976
Mailing Address - Fax:321-453-8976
Practice Address - Street 1:2070 TEMPLE AVE
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-4221
Practice Address - Country:US
Practice Address - Phone:321-453-8976
Practice Address - Fax:321-453-8976
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-28
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
No373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL676830098Medicaid
FL676830096Medicaid