Provider Demographics
NPI:1609320449
Name:HOLLIS, REBECCA
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:HOLLIS
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 1:7125 W ENCANTO BLVD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85035-1335
Mailing Address - Country:US
Mailing Address - Phone:623-961-5615
Mailing Address - Fax:623-691-5620
Practice Address - Street 1:7125 W ENCANTO BLVD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85035-1335
Practice Address - Country:US
Practice Address - Phone:623-961-5615
Practice Address - Fax:623-691-5620
Is Sole Proprietor?:No
Enumeration Date:2016-08-10
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP051647164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse