Healthcare Provider Details

I. General information

NPI: 1063860997
Provider Name (Legal Business Name): JOELLE HOLLAND
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2016
Last Update Date: 09/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 WESTFALEN TRL
MEDINA MN
55340-4621
US

IV. Provider business mailing address

170 WESTFALEN TRL
MEDINA MN
55340-4621
US

V. Phone/Fax

Practice location:
  • Phone: 763-478-3505
  • Fax:
Mailing address:
  • Phone: 763-478-3505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3470
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: