Provider Demographics
NPI:1558613695
Name:AUTRY, HOLLY (LDO)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:AUTRY
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 WOODLAWN AVE
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:GA
Mailing Address - Zip Code:30228-2948
Mailing Address - Country:US
Mailing Address - Phone:404-486-3366
Mailing Address - Fax:678-759-2319
Practice Address - Street 1:22 E MAIN ST N
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:GA
Practice Address - Zip Code:30228-5502
Practice Address - Country:US
Practice Address - Phone:404-486-3366
Practice Address - Fax:404-920-4747
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-13
Last Update Date:2012-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALDO002203156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician