Provider Demographics
NPI:1710639521
Name:MOULING, HOLLEY S
Entity Type:Individual
Prefix:
First Name:HOLLEY
Middle Name:S
Last Name:MOULING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HOLLEY
Other - Middle Name:S
Other - Last Name:MOULING
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:10120 CANDLEBERRY WOODS LN
Mailing Address - Street 2:
Mailing Address - City:GIBSONTON
Mailing Address - State:FL
Mailing Address - Zip Code:33534-5706
Mailing Address - Country:US
Mailing Address - Phone:813-521-9546
Mailing Address - Fax:
Practice Address - Street 1:10120 CANDLEBERRY WOODS LN
Practice Address - Street 2:
Practice Address - City:GIBSONTON
Practice Address - State:FL
Practice Address - Zip Code:33534-5706
Practice Address - Country:US
Practice Address - Phone:813-521-9546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-23
Last Update Date:2022-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL024670700Medicaid