1053744391 NPI number — MRS. HEATHER BROOM HOLDINESS APRN

Table of content: MRS. HEATHER BROOM HOLDINESS APRN (NPI 1053744391)

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".




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