MEDICARE: LACY NICHOLE HOLLOWELL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1861352528
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LACY NICHOLE HOLLOWELL

Provider Business Mailing Address
First Line	:	642 FRONT AVE APT G4
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55103-1415
Country	:	US
Telephone Number	:	731-358-8623
Fax Number	:

Provider Business Practice Location Address
First Line	:	5010 CHESHIRE LN N
Second Line	:
City	:	PLYMOUTH
State	:	MN
Zip	:	55446-3863
Country	:	US
Telephone Number	:	612-439-4650
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/14/2025
Last Update Date	:	11/14/2025

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