Provider Demographics
NPI:1124766217
Name:LOWRY, HOLLY MARIE (MA)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:MARIE
Last Name:LOWRY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:MARIE
Other - Last Name:LOWRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4639 REED RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46835-3543
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4639 REED RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46835-3543
Practice Address - Country:US
Practice Address - Phone:260-797-6421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-26
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
B6H8B6K4246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INB6H8B6K4Medicaid