=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194210070
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAIME MARIE HOLTHAUS APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/25/2018
-----------------------------------------------------
Last Update Date | 06/25/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3101 SE 14TH ST
-----------------------------------------------------
City | BENTONVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72712-4900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-986-6090
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 713 COULTER RD
-----------------------------------------------------
City | SHERWOOD
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72120-5917
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-864-9460
-----------------------------------------------------
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 | A005688
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------