Healthcare Provider Details

I. General information

NPI: 1902235088
Provider Name (Legal Business Name): MICHELLE HOLMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2013
Last Update Date: 11/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 AVENUE 64
PASADENA CA
91105
US

IV. Provider business mailing address

940 AVENUE 64
PASADENA CA
91105-2711
US

V. Phone/Fax

Practice location:
  • Phone: 323-254-2274
  • Fax:
Mailing address:
  • Phone: 323-254-2274
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number243866
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number243866
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: