Provider Demographics
NPI:1982084190
Name:MEDLEN, HOLLY (AANP CNP)
Entity Type:Individual
Prefix:MRS
First Name:HOLLY
Middle Name:
Last Name:MEDLEN
Suffix:
Gender:F
Credentials:AANP CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2213 CHERRY ST UNIT 2B
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43608-2603
Mailing Address - Country:US
Mailing Address - Phone:419-251-5155
Mailing Address - Fax:
Practice Address - Street 1:2213 CHERRY ST UNIT 2B
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43608
Practice Address - Country:US
Practice Address - Phone:419-251-5155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-02
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA17303-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0141539Medicaid
OH0141539Medicaid