Healthcare Provider Details

I. General information

NPI: 1275522708
Provider Name (Legal Business Name): BREENA W HOLMES MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/18/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 PORTER DR
MIDDLEBURY VT
05753-8527
US

IV. Provider business mailing address

104 PORTER DR
MIDDLEBURY VT
05753-8527
US

V. Phone/Fax

Practice location:
  • Phone: 802-388-7959
  • Fax:
Mailing address:
  • Phone: 802-388-8808
  • Fax: 802-388-8322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0420009478
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: