Basic Information
| Provider Information | |||||||||
| NPI: | 1548378615 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOLLOWAY | ||||||||
| FirstName: | KIM | ||||||||
| MiddleName: | |||||||||
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| Credential: | CRNA | ||||||||
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| OtherLastName: | HOLLOWAY | ||||||||
| OtherFirstName: | KIM | ||||||||
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| OtherCredential: | CRNA | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3107 PROMENADE CIR | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481081559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342768054 | ||||||||
| FaxNumber: | 9524423630 | ||||||||
| Practice Location | |||||||||
| Address1: | 159 KERCHEVAL AVE | ||||||||
| Address2: | |||||||||
| City: | GROSSE POINTE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5865691329 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2006 | ||||||||
| LastUpdateDate: | 07/17/2018 | ||||||||
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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 | 367500000X | 4704222209 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 104820177 | 05 | MI | MEDICAID | KC222209 | 01 | MI | BLUE CROSS OF MI | OTHER |