Provider Demographics
NPI:1952664237
Name:LEWIS, HOLLY DELAYNE
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:DELAYNE
Last Name:LEWIS
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 1:5608 MARTY LN
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-8321
Mailing Address - Country:US
Mailing Address - Phone:336-244-5471
Mailing Address - Fax:
Practice Address - Street 1:333 E LEE AVE
Practice Address - Street 2:
Practice Address - City:YADKINVILLE
Practice Address - State:NC
Practice Address - Zip Code:27055-8132
Practice Address - Country:US
Practice Address - Phone:336-679-8028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-21
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA3957225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant