Provider Demographics
NPI:1689180507
Name:HOLMES, MARKEYSHA RENA
Entity Type:Individual
Prefix:
First Name:MARKEYSHA
Middle Name:RENA
Last Name:HOLMES
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 1:2607 LEDO RD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31707-1211
Mailing Address - Country:US
Mailing Address - Phone:229-903-0022
Mailing Address - Fax:
Practice Address - Street 1:2607 LEDO RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-1211
Practice Address - Country:US
Practice Address - Phone:229-903-0022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-15
Last Update Date:2017-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHTC007718183700000X
GALPN091032164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA056095298Medicaid