Provider Demographics
NPI:1649691502
Name:NELSON, HOLLEY
Entity type:Individual
Prefix:
First Name:HOLLEY
Middle Name:
Last Name:NELSON
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 1:2120 E MONONA DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85024-4417
Mailing Address - Country:US
Mailing Address - Phone:602-867-9011
Mailing Address - Fax:
Practice Address - Street 1:2120 E MONONA DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85024-4417
Practice Address - Country:US
Practice Address - Phone:602-867-9011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-19
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP047799164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse