Provider Demographics
NPI:1689118887
Name:HANCOCK, HOLLY
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:HANCOCK
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 1:1 FORD PL STE 3A
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-3450
Mailing Address - Country:US
Mailing Address - Phone:313-874-4806
Mailing Address - Fax:
Practice Address - Street 1:6777 W MAPLE RD
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3013
Practice Address - Country:US
Practice Address - Phone:248-325-0636
Practice Address - Fax:248-325-0640
Is Sole Proprietor?:No
Enumeration Date:2016-12-07
Last Update Date:2025-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0021344367500000X
MI4704345820367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered