Healthcare Provider Details

I. General information

NPI: 1124007794
Provider Name (Legal Business Name): JANE A HOLM C.R.N.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2006
Last Update Date: 05/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6500 EXCELSIOR BLVD
ST LOUIS PARK MN
55426-4702
US

IV. Provider business mailing address

6465 WAYZATA BLVD STE 315
ST LOUIS PARK MN
55426-1728
US

V. Phone/Fax

Practice location:
  • Phone: 952-993-5222
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR 100791-8
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: