1467475939 NPI number — MS. DIANE P HOLZEM RN,C

Table of content: MS. DIANE P HOLZEM RN,C (NPI 1467475939)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467475939 NPI number — MS. DIANE P HOLZEM RN,C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOLZEM
Provider First Name:
DIANE
Provider Middle Name:
P
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
RN,C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PINARD
Provider Other First Name:
DIANE
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
RN,C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1467475939
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/23/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 187
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DULCE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87528-0187
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-759-7233
Provider Business Mailing Address Fax Number:
505-759-7294

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12000 STONE LAKE ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DULCE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87528-0187
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-759-7233
Provider Business Practice Location Address Fax Number:
505-759-7294
Provider Enumeration Date:
07/25/2006

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: 163W00000X , with the licence number:  R17040 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000K3526 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: HSZ196 . This is a "MEDICARE PART B" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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