Provider Demographics
NPI:1619712569
Name:HOLM, HOLLY LOA
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:LOA
Last Name:HOLM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 NORWAY ST STE 1
Mailing Address - Street 2:
Mailing Address - City:GRAYLING
Mailing Address - State:MI
Mailing Address - Zip Code:49738-1717
Mailing Address - Country:US
Mailing Address - Phone:231-349-7487
Mailing Address - Fax:
Practice Address - Street 1:501 NORWAY ST STE 1
Practice Address - Street 2:
Practice Address - City:GRAYLING
Practice Address - State:MI
Practice Address - Zip Code:49738-1717
Practice Address - Country:US
Practice Address - Phone:231-349-7487
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-01
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker