Provider Demographics
NPI:1770978710
Name:ETTENHOFER, HOLLY JO
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:JO
Last Name:ETTENHOFER
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 1:6320 SOUTH 6TH STREET
Mailing Address - Street 2:
Mailing Address - City:WELLS
Mailing Address - State:MI
Mailing Address - Zip Code:49894
Mailing Address - Country:US
Mailing Address - Phone:906-553-1610
Mailing Address - Fax:
Practice Address - Street 1:6320 S 6TH ST
Practice Address - Street 2:
Practice Address - City:WELLS
Practice Address - State:MI
Practice Address - Zip Code:49894-9701
Practice Address - Country:US
Practice Address - Phone:906-553-1610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-06
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer