Healthcare Provider Details

I. General information

NPI: 1376090977
Provider Name (Legal Business Name): AUDREY HOLLAND
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 09/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2965 EAST 109TH AVENUE SPECIALTY FOOT CARE LLC
NORTHGLENN CO
80233
US

IV. Provider business mailing address

2965 E 109TH AVE
NORTHGLENN CO
80233-5475
US

V. Phone/Fax

Practice location:
  • Phone: 303-980-0015
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0109418
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: