Provider Demographics
NPI:1902435464
Name:HOLLEY, KAYLEE (CCHT)
Entity Type:Individual
Prefix:
First Name:KAYLEE
Middle Name:
Last Name:HOLLEY
Suffix:
Gender:F
Credentials:CCHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2420 K ST SE
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98002-7629
Mailing Address - Country:US
Mailing Address - Phone:253-202-3834
Mailing Address - Fax:
Practice Address - Street 1:12901 20TH AVE S
Practice Address - Street 2:
Practice Address - City:SEATAC
Practice Address - State:WA
Practice Address - Zip Code:98168-5159
Practice Address - Country:US
Practice Address - Phone:253-202-3834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-06
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAHC603381592472R0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2472R0900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherRenal Dialysis
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAHC60338159Medicaid
WAHT60369858Medicaid