Healthcare Provider Details

I. General information

NPI: 1578172185
Provider Name (Legal Business Name): ELIZABETH HOLMES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2020
Last Update Date: 07/29/2020
Certification Date: 07/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3119 W FAIDLEY AVE
GRAND ISLAND NE
68803-4114
US

IV. Provider business mailing address

1832 W 12TH ST
GRAND ISLAND NE
68803-3715
US

V. Phone/Fax

Practice location:
  • Phone: 308-384-2333
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number1118
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: