Healthcare Provider Details

I. General information

NPI: 1003225533
Provider Name (Legal Business Name): KATINA LATRICE HOLLIDAY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2014
Last Update Date: 08/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 E COMPTON BLVD
COMPTON CA
90221-3663
US

IV. Provider business mailing address

14608 VAN NESS AVE
GARDENA CA
90249-3258
US

V. Phone/Fax

Practice location:
  • Phone: 213-488-9559
  • Fax:
Mailing address:
  • Phone: 310-493-2769
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95000731
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number561948
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: