Provider Demographics
NPI:1144647652
Name:HOLLEY, STACY (FNP)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:HOLLEY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:BROOKE
Other - Last Name:MENIX-LAYNE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP
Mailing Address - Street 1:107 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GRAYSON
Mailing Address - State:KY
Mailing Address - Zip Code:41143-1301
Mailing Address - Country:US
Mailing Address - Phone:606-474-0244
Mailing Address - Fax:606-474-0412
Practice Address - Street 1:107 E MAIN ST
Practice Address - Street 2:
Practice Address - City:GRAYSON
Practice Address - State:KY
Practice Address - Zip Code:41143-1301
Practice Address - Country:US
Practice Address - Phone:606-474-0244
Practice Address - Fax:606-474-0412
Is Sole Proprietor?:No
Enumeration Date:2014-03-21
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV84657363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0102228Medicaid
WV3053133OtherBCBS
KY7100295790Medicaid
KY7100295790Medicaid