Provider Demographics
NPI:1639535628
Name:LAVENDER, HOLLY (FNP)
Entity Type:Individual
Prefix:MS
First Name:HOLLY
Middle Name:
Last Name:LAVENDER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:E
Other - Last Name:CLEMENTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1016 KEITH DR
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:GA
Mailing Address - Zip Code:31069
Mailing Address - Country:US
Mailing Address - Phone:478-988-1515
Mailing Address - Fax:478-988-1550
Practice Address - Street 1:1016 KEITH DR
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:GA
Practice Address - Zip Code:31069
Practice Address - Country:US
Practice Address - Phone:478-988-1515
Practice Address - Fax:478-988-1550
Is Sole Proprietor?:No
Enumeration Date:2016-01-07
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN184680363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily