Provider Demographics
NPI:1639920788
Name:SMITH, HOLLY (LPN)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:167 N DRAKE RD
Mailing Address - Street 2:P.O BOX 20421
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1109 COBB AVE
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-2449
Practice Address - Country:US
Practice Address - Phone:910-650-8828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-28
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1710I1003X, 171400000X, 374U00000X
MI4703120614164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians
No171400000XOther Service ProvidersHealth & Wellness Coach
No374U00000XNursing Service Related ProvidersHome Health Aide