Provider Demographics
NPI:1063551018
Name:HARRIS, HOLLEY CABALLES
Entity type:Individual
Prefix:
First Name:HOLLEY
Middle Name:CABALLES
Last Name:HARRIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3702 S TIMBERLINE RD STE A
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-3625
Mailing Address - Country:US
Mailing Address - Phone:970-207-9773
Mailing Address - Fax:970-207-1893
Practice Address - Street 1:2555 E 13TH ST STE 220
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80537-5136
Practice Address - Country:US
Practice Address - Phone:970-669-5432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COC-APN.0001411-C-CRNA367500000X
TXAP115754367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX193863101Medicaid
TXP00624953OtherMEDICARE RAILROAD
TX193863103Medicaid
TX87625UOtherBLUE CROSS PROVIDER ID
TX193863101Medicaid
TX331320YK6UMedicare PIN