Basic Information
| Provider Information | |||||||||
| NPI: | 1033407713 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHANEY | ||||||||
| FirstName: | HOLLY | ||||||||
| MiddleName: | WELLMAN TRAVIS | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7777 BLUEBONNET BLVD. STE 100 | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257669091 | ||||||||
| FaxNumber: | 2257669317 | ||||||||
| Practice Location | |||||||||
| Address1: | 7777 BLUEBONNET BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708101632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257669091 | ||||||||
| FaxNumber: | 2257669317 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2011 | ||||||||
| LastUpdateDate: | 03/17/2016 | ||||||||
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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 | 363LF0000X | AP06560 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | AP06560 | LA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 2157060 | 05 | LA | MEDICAID |