Provider Demographics
NPI:1932629458
Name:HOLLEY, LYDIA JEAN EVA (LPN)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:JEAN EVA
Last Name:HOLLEY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:LYDIA
Other - Middle Name:JEAN EVA
Other - Last Name:GRAHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6350 W ANDREW JOHNSON HWY DEPT 100
Mailing Address - Street 2:
Mailing Address - City:TALBOTT
Mailing Address - State:TN
Mailing Address - Zip Code:37877-8605
Mailing Address - Country:US
Mailing Address - Phone:800-355-3565
Mailing Address - Fax:423-714-2355
Practice Address - Street 1:1032 MCCALLIE AVE
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-2800
Practice Address - Country:US
Practice Address - Phone:423-266-4588
Practice Address - Fax:865-342-0103
Is Sole Proprietor?:No
Enumeration Date:2017-06-26
Last Update Date:2017-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLPN85830164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse