Provider Demographics
NPI:1861932154
Name:HOLLAND, MARILYN GRIBBLE (APRN)
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:GRIBBLE
Last Name:HOLLAND
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MARILYN
Other - Middle Name:FRANCIS
Other - Last Name:GRIBBLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:PO BOX 122425 DEPT 2425
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75312-2425
Mailing Address - Country:US
Mailing Address - Phone:337-494-2921
Mailing Address - Fax:337-494-6523
Practice Address - Street 1:2770 3RD AVE STE 110
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-0404
Practice Address - Country:US
Practice Address - Phone:337-494-4747
Practice Address - Fax:337-494-4773
Is Sole Proprietor?:No
Enumeration Date:2017-03-06
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP09148363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAAP09148OtherSTATE LICENSE
LA2441612Medicaid