Provider Demographics
NPI:1588250286
Name:HOLLOWAY, JAVON LAURICE
Entity type:Individual
Prefix:
First Name:JAVON
Middle Name:LAURICE
Last Name:HOLLOWAY
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 1:1495 E 173RD ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44110-2932
Mailing Address - Country:US
Mailing Address - Phone:216-512-3683
Mailing Address - Fax:
Practice Address - Street 1:1495 EAST 173RD STRRET DOWN
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44110
Practice Address - Country:US
Practice Address - Phone:216-512-3683
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-16
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0326023Medicaid