Provider Demographics
NPI:1295417244
Name:HOLCOMB, ADEIA CHANTA (LPN)
Entity type:Individual
Prefix:
First Name:ADEIA
Middle Name:CHANTA
Last Name:HOLCOMB
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:452 OLIVER ST APT 1
Mailing Address - Street 2:
Mailing Address - City:NORTH TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14120-6961
Mailing Address - Country:US
Mailing Address - Phone:716-553-6429
Mailing Address - Fax:
Practice Address - Street 1:500 SENECA ST STE 610
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14204-1963
Practice Address - Country:US
Practice Address - Phone:716-881-2800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-01
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY344658-01164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty