Healthcare Provider Details

I. General information

NPI: 1336765007
Provider Name (Legal Business Name): HOLLY MARIE CROTEAU RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2020
Last Update Date: 05/11/2023
Certification Date: 05/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12625 HESPERIA RD
VICTORVILLE CA
92395-7720
US

IV. Provider business mailing address

303 E VANDERBILT WAY
SAN BERNARDINO CA
92415-0026
US

V. Phone/Fax

Practice location:
  • Phone: 760-995-8300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number780137
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: