Provider Demographics
NPI:1013112556
Name:LUCILLE, HOLLY (ND)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:LUCILLE
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 N CROFT AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90069-4298
Mailing Address - Country:US
Mailing Address - Phone:310-709-6519
Mailing Address - Fax:815-425-8815
Practice Address - Street 1:7235 SANTA MONICA BLVD
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90046-6724
Practice Address - Country:US
Practice Address - Phone:323-658-9151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-15
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAND-70207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine