Healthcare Provider Details

I. General information

NPI: 1598429300
Provider Name (Legal Business Name): HENRICK KARL HOLMBERG RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2021
Last Update Date: 10/27/2021
Certification Date: 09/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CORNER OF NR 7 & NR 12
FORT DEFIANCE AZ
86504
US

IV. Provider business mailing address

PO BOX 649
FORT DEFIANCE AZ
86504-0649
US

V. Phone/Fax

Practice location:
  • Phone: 928-729-8581
  • Fax:
Mailing address:
  • Phone: 928-729-8581
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number1-138207
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License NumberRN198338
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: