Healthcare Provider Details

I. General information

NPI: 1083306542
Provider Name (Legal Business Name): HOLLY LYNN NIKODYM FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2023
Last Update Date: 05/23/2023
Certification Date: 05/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 SAN BERNARDINO RD STE 300
UPLAND CA
91786-7299
US

IV. Provider business mailing address

901 SAN BERNARDINO RD STE 300
UPLAND CA
91786-7299
US

V. Phone/Fax

Practice location:
  • Phone: 909-579-6753
  • Fax:
Mailing address:
  • Phone: 909-579-6753
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95025306
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: