Provider Demographics
NPI:1497039143
Name:HOLLOWAY, LANISHA J
Entity Type:Individual
Prefix:MRS
First Name:LANISHA
Middle Name:J
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 1:8225 LEAFCREST DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32244-7493
Mailing Address - Country:US
Mailing Address - Phone:904-210-2685
Mailing Address - Fax:904-438-5726
Practice Address - Street 1:5022 PERRINE DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-7859
Practice Address - Country:US
Practice Address - Phone:904-772-0651
Practice Address - Fax:904-438-5726
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-29
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12059310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility