Provider Demographics
NPI:1548378615
Name:HOLLOWAY, KIM (CRNA)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:HOLLOWAY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:
Other - Last Name:HOLLOWAY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CRNA
Mailing Address - Street 1:3107 PROMENADE CIR
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-1559
Mailing Address - Country:US
Mailing Address - Phone:734-276-8054
Mailing Address - Fax:952-442-3630
Practice Address - Street 1:159 KERCHEVAL AVE
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE
Practice Address - State:MI
Practice Address - Zip Code:48236
Practice Address - Country:US
Practice Address - Phone:586-569-1329
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704222209367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104820177Medicaid
MIKC222209OtherBLUE CROSS OF MI
MIKC222209OtherBLUE CROSS OF MI
MI104820177Medicaid