Healthcare Provider Details

I. General information

NPI: 1538058722
Provider Name (Legal Business Name): HOLLY J BROOKS LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HOLLY JO BOLT LPN

II. Dates (important events)

Enumeration Date: 07/01/2025
Last Update Date: 07/01/2025
Certification Date: 06/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27TH SPECIAL OPERATIONS MEDICAL GROUP 224 W. D.L. INGRAM AVENUE, BLDG. 1408
CANNON AFB NM
88103
US

IV. Provider business mailing address

27TH SPECIAL OPERATIONS MEDICAL GROUP 224 W. D.L. INGRAM AVENUE, BLDG. 1408
CANNON AFB NM
88103
US

V. Phone/Fax

Practice location:
  • Phone: 575-784-2778
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number1108222
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: