Provider Demographics
NPI:1437623162
Name:HOLINESS, ANGENETTE
Entity type:Individual
Prefix:
First Name:ANGENETTE
Middle Name:
Last Name:HOLINESS
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 1:22000 BALL AVE
Mailing Address - Street 2:
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44123-2706
Mailing Address - Country:US
Mailing Address - Phone:216-200-3821
Mailing Address - Fax:
Practice Address - Street 1:22000 BALL AVE
Practice Address - Street 2:
Practice Address - City:EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44123-2706
Practice Address - Country:US
Practice Address - Phone:216-200-3821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-16
Last Update Date:2022-11-29
Deactivation Date:2020-12-01
Deactivation Code:
Reactivation Date:2022-11-29
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372500000XNursing Service Related ProvidersChore Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0323147Medicaid