Healthcare Provider Details

I. General information

NPI: 1477465805
Provider Name (Legal Business Name): ANGELICA LATRICE BIANCA HOLMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHOMBE JACKSON

II. Dates (important events)

Enumeration Date: 09/21/2026
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9980 HOLLY LN
DES PLAINES IL
60016-1423
US

IV. Provider business mailing address

9980 HOLLY LN
DES PLAINES IL
60016-1423
US

V. Phone/Fax

Practice location:
  • Phone: 984-381-1603
  • Fax:
Mailing address:
  • Phone: 984-381-1603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberMIGHTY1
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: