Provider Demographics
NPI:1942671706
Name:COFFEY, HOLLY
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:COFFEY
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:PO BOX 1171
Mailing Address - Street 2:
Mailing Address - City:LOCUST GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74352-1171
Mailing Address - Country:US
Mailing Address - Phone:918-798-1594
Mailing Address - Fax:
Practice Address - Street 1:6129 E 570 RD
Practice Address - Street 2:
Practice Address - City:LOCUST GROVE
Practice Address - State:OK
Practice Address - Zip Code:74352-6104
Practice Address - Country:US
Practice Address - Phone:918-798-1594
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-19
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide