Basic Information
| Provider Information | |||||||||
| NPI: | 1033448642 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOLLEY | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | CAROLINE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | AU.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 400 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383020400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7314238697 | ||||||||
| FaxNumber: | 7314225743 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 W FOREST AVE | ||||||||
| Address2: | STE. 300 | ||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383013937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7314220340 | ||||||||
| FaxNumber: | 7314220319 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2009 | ||||||||
| LastUpdateDate: | 07/19/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 1057A | AL | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 1525271 | 05 | TN | MEDICAID |