Provider Demographics
NPI:1134665417
Name:O'ROURKE, HOLLY (CRNA)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:O'ROURKE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:
Other - Last Name:LEDOUX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4422 VIA MARINA # P712
Mailing Address - Street 2:APT P712
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6890
Mailing Address - Country:US
Mailing Address - Phone:940-642-5094
Mailing Address - Fax:
Practice Address - Street 1:4422 VIA MARINA #P712
Practice Address - Street 2:APT P712
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-6890
Practice Address - Country:US
Practice Address - Phone:940-642-5094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-11
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA112562367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered