=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447025994
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CASSANDRA MARIE HOLMES
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2023
-----------------------------------------------------
Last Update Date | 11/15/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 47601 GRAND RIVER AVE
-----------------------------------------------------
City | NOVI
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48374-1233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-465-4100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6151 KINYON DR
-----------------------------------------------------
City | BRIGHTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48116-9580
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-623-8377
-----------------------------------------------------
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 | 4704319020
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------