=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003225533
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATINA LATRICE HOLLIDAY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/08/2014
-----------------------------------------------------
Last Update Date | 08/26/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4200 E COMPTON BLVD
-----------------------------------------------------
City | COMPTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90221-3663
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-488-9559
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14608 VAN NESS AVE
-----------------------------------------------------
City | GARDENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90249-3258
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-493-2769
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 95000731
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 561948
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------