Healthcare Provider Details

I. General information

NPI: 1154499671
Provider Name (Legal Business Name): WYNEMA HOLMES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 01/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HWY 160/163, BLDG KA 2010
KAYENTA AZ
86033-0368
US

IV. Provider business mailing address

HWY 160/163, BLDG KA 2010
KAYENTA AZ
86033-0368
US

V. Phone/Fax

Practice location:
  • Phone: 928-697-4000
  • Fax: 928-697-4083
Mailing address:
  • Phone: 928-697-4000
  • Fax: 928-697-4083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License NumberRN055930
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: