Healthcare Provider Details

I. General information

NPI: 1144804550
Provider Name (Legal Business Name): HOLLY ANNE GLOUDEMANS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: HOLLY ANNE HANSON

II. Dates (important events)

Enumeration Date: 05/11/2021
Last Update Date: 03/03/2025
Certification Date: 02/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 N LA CIENEGA BLVD STE M102
BEVERLY HILLS CA
90211-2288
US

IV. Provider business mailing address

4140 W 190TH ST
TORRANCE CA
90504-5513
US

V. Phone/Fax

Practice location:
  • Phone: 310-358-2992
  • Fax: 310-358-2973
Mailing address:
  • Phone: 310-385-2992
  • Fax: 310-385-2973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number95017289
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95017289
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: