Healthcare Provider Details

I. General information

NPI: 1770948234
Provider Name (Legal Business Name): LATRECE HOLLOWAY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2015
Last Update Date: 03/24/2026
Certification Date: 03/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19600 E 39TH ST S
INDEPENDENCE MO
64057-2301
US

IV. Provider business mailing address

3338 S NORWOOD AVE
INDEPENDENCE MO
64052-2724
US

V. Phone/Fax

Practice location:
  • Phone: 816-462-7612
  • Fax:
Mailing address:
  • Phone: 816-462-7612
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2016012516
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2010038006
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: