Provider Demographics
NPI:1639392459
Name:HOLLOWAY, SAMANTHA M
Entity Type:Individual
Prefix:MISS
First Name:SAMANTHA
Middle Name:M
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 1:4415 N PERSHING AVE APT 17
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207
Mailing Address - Country:US
Mailing Address - Phone:209-476-0358
Mailing Address - Fax:
Practice Address - Street 1:1212 N CALIFORNIA ST.
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95202
Practice Address - Country:US
Practice Address - Phone:209-468-8660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32576167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician