Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207K00000X | Allergist & Immunologist | 034852 | GA |
Y | 207Q00000X | Family Doctor | 034852 | GA |
NPI | 1063584324 |
---|---|
Provider Name | Dr. Regina Lorren Holloway |
First Address | Bremen, GA 30110 |
Second Address | Bremen, GA 30110 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/11/2006 |
Last Update Date | 14/07/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00478552H | (05) | GA |
021201960A | CAID PAYEE (01) | GA |
142710464A | GBHC (01) | GA |
F17566 | (02) |