Provider Demographics
NPI:1003225533
Name:HOLLIDAY, KATINA LATRICE
Entity Type:Individual
Prefix:
First Name:KATINA
Middle Name:LATRICE
Last Name:HOLLIDAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14608 VAN NESS AVE
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90249-3258
Mailing Address - Country:US
Mailing Address - Phone:310-493-2769
Mailing Address - Fax:
Practice Address - Street 1:4200 E COMPTON BLVD
Practice Address - Street 2:
Practice Address - City:COMPTON
Practice Address - State:CA
Practice Address - Zip Code:90221-3663
Practice Address - Country:US
Practice Address - Phone:213-488-9559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-08
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95000731363LF0000X
CA561948163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse