Provider Demographics
NPI:1588220404
Name:HOLLIS, DAFFENEY (CNA)
Entity Type:Individual
Prefix:
First Name:DAFFENEY
Middle Name:
Last Name:HOLLIS
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8495
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31095-8495
Mailing Address - Country:US
Mailing Address - Phone:478-662-8285
Mailing Address - Fax:
Practice Address - Street 1:1205 LEVERETT RD APT 1204
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-0332
Practice Address - Country:US
Practice Address - Phone:478-662-8285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-16
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA343900000X, 3747P1801X, 374U00000X, 376J00000X
GACN0000022932376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376K00000XNursing Service Related ProvidersNurse's AideGroup - Multi-Specialty
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No374U00000XNursing Service Related ProvidersHome Health Aide
No376J00000XNursing Service Related ProvidersHomemaker