Provider Demographics
NPI:1013630797
Name:HOLLEY, TARA ASHLEY (FNP)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:ASHLEY
Last Name:HOLLEY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:ASHLEY
Other - Last Name:COX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 508
Mailing Address - Street 2:
Mailing Address - City:SHADY COVE
Mailing Address - State:OR
Mailing Address - Zip Code:97539-0508
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21990 HIGHWAY 62
Practice Address - Street 2:
Practice Address - City:SHADY COVE
Practice Address - State:OR
Practice Address - Zip Code:97539-9717
Practice Address - Country:US
Practice Address - Phone:541-878-2022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-19
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY50884363LF0000X, 363LX0001X
OR10009584363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology