Healthcare Provider Details

I. General information

NPI: 1790127967
Provider Name (Legal Business Name): JACQUELINE PRISCILLIA HOLMES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2013
Last Update Date: 02/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5834 ARUBA WAY
WEST PALM BCH FL
33407-1708
US

IV. Provider business mailing address

5834 ARUBA WAY
WEST PALM BCH FL
33407-1708
US

V. Phone/Fax

Practice location:
  • Phone: 904-554-0628
  • Fax:
Mailing address:
  • Phone: 904-554-0628
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number136394
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: