Healthcare Provider Details

I. General information

NPI: 1841693892
Provider Name (Legal Business Name): IRENE BENALLY-HOLMES RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2014
Last Update Date: 10/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HIGHWAY 264 MILEPOST 388
POLSCCA AZ
86042
US

IV. Provider business mailing address

PO BOX 4000
POLACCA AZ
86042-4000
US

V. Phone/Fax

Practice location:
  • Phone: 928-737-6003
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN169674
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: