Provider Demographics
NPI:1871051219
Name:CAMPUZANO, HOLLY
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:CAMPUZANO
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:PO BOX 383
Mailing Address - Street 2:
Mailing Address - City:AVILA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93424-0383
Mailing Address - Country:US
Mailing Address - Phone:805-602-7068
Mailing Address - Fax:
Practice Address - Street 1:2178 JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-4535
Practice Address - Country:US
Practice Address - Phone:805-781-4712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-05
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA268344164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse