Basic Information
| Provider Information | |||||||||
| NPI: | 1437586583 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HARRIS | ||||||||
| FirstName: | HOLLEY | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | APN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25 N WINFIELD RD | ||||||||
| Address2: | |||||||||
| City: | WINFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601901295 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302320280 | ||||||||
| FaxNumber: | 6302323895 | ||||||||
| Practice Location | |||||||||
| Address1: | 351 DELNOR DR | ||||||||
| Address2: | |||||||||
| City: | GENEVA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601344220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302320280 | ||||||||
| FaxNumber: | 6302323895 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2013 | ||||||||
| LastUpdateDate: | 09/12/2018 | ||||||||
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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 | 363LF0000X | 209010766 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 209.010766 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 206147 | 01 | IL | MEDICARE GROUP PTAN | OTHER | F400439285 | 01 | IL | MEDICARE INDIVIDUAL PTAN | OTHER |