Healthcare Provider Details

I. General information

NPI: 1528425923
Provider Name (Legal Business Name): TARA HOLMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2016
Last Update Date: 01/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6600 STATE HIGHWAY 29 S
ALEXANDRIA MN
56308-6196
US

IV. Provider business mailing address

PO BOX 334
ALEXANDRIA MN
56308-0334
US

V. Phone/Fax

Practice location:
  • Phone: 320-763-8888
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberL074586-0
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: