1053744391 NPI number — MRS. HEATHER BROOM HOLDINESS APRN

Table of content: DR. PATRICK LABELLE D.C. (NPI 1194804799)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053744391 NPI number — MRS. HEATHER BROOM HOLDINESS APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOLDINESS
Provider First Name:
HEATHER
Provider Middle Name:
BROOM
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
APRN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053744391
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8333 N DAVIS HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PENSACOLA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32514-6050
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-474-8385
Provider Business Mailing Address Fax Number:
850-969-2904

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
903 DESOTO BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOT SPRINGS VILLAGE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71909-6100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-922-6266
Provider Business Practice Location Address Fax Number:
501-922-8122
Provider Enumeration Date:
08/09/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2100X , with the licence number:  A004582 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LG0600X , with the licence number: A004582 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LA2200X , with the licence number: A004582 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 06336908 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 212780758 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 103967300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com