Provider Demographics
NPI:1679350680
Name:DAVIS, HOLLY R (PTA)
Entity Type:Individual
Prefix:MISS
First Name:HOLLY
Middle Name:R
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MRS
Other - First Name:HOLLY
Other - Middle Name:RENA
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:215 THACH LN
Mailing Address - Street 2:
Mailing Address - City:MERIDIANVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35759-1625
Mailing Address - Country:US
Mailing Address - Phone:256-788-7712
Mailing Address - Fax:
Practice Address - Street 1:24623 UNION HILL RD
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:TN
Practice Address - Zip Code:38449-3101
Practice Address - Country:US
Practice Address - Phone:931-427-2143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-12
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7566314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility