Provider Demographics
NPI:1689866485
Name:HOLLY, LAVERNE (RN)
Entity Type:Individual
Prefix:
First Name:LAVERNE
Middle Name:
Last Name:HOLLY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 30
Mailing Address - Street 2:
Mailing Address - City:TEEC NOS POS
Mailing Address - State:AZ
Mailing Address - Zip Code:86514-0030
Mailing Address - Country:US
Mailing Address - Phone:928-656-5492
Mailing Address - Fax:928-656-5452
Practice Address - Street 1:JCT U.S.HWY 160 & NAVAJO RT 35
Practice Address - Street 2:
Practice Address - City:RED MESA
Practice Address - State:AZ
Practice Address - Zip Code:86514
Practice Address - Country:US
Practice Address - Phone:928-656-5492
Practice Address - Fax:928-656-5452
Is Sole Proprietor?:No
Enumeration Date:2007-08-15
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR45979163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care