Provider Demographics
NPI:1932383254
Name:HOLLEY, RENEE KATHLEEN (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:RENEE
Middle Name:KATHLEEN
Last Name:HOLLEY
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:RENEE
Other - Middle Name:KATHLEEN CONNER
Other - Last Name:ROGERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7222 ENGLE ROAD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-2222
Mailing Address - Country:US
Mailing Address - Phone:260-432-5005
Mailing Address - Fax:260-432-6003
Practice Address - Street 1:7222 ENGLE ROAD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-2222
Practice Address - Country:US
Practice Address - Phone:260-432-5005
Practice Address - Fax:260-432-6003
Is Sole Proprietor?:No
Enumeration Date:2007-12-21
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002132A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN20088850Medicaid
P00689114OtherRAILROAD MEDICARE
237770EMedicare PIN