Provider Demographics
NPI:1659085108
Name:ELLIS, HOLLY BETH
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:BETH
Last Name:ELLIS
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 1:223 DEREK DR
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:26537-1742
Mailing Address - Country:US
Mailing Address - Phone:304-435-8713
Mailing Address - Fax:
Practice Address - Street 1:223 DEREK DR
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:WV
Practice Address - Zip Code:26537-1742
Practice Address - Country:US
Practice Address - Phone:304-435-8713
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-10
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant