Provider Demographics
NPI:1043336183
Name:HOLM, BONNY J (LPN)
Entity Type:Individual
Prefix:
First Name:BONNY
Middle Name:J
Last Name:HOLM
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:167 S SANTA CLAUS LN
Mailing Address - Street 2:
Mailing Address - City:NORTH POLE
Mailing Address - State:AK
Mailing Address - Zip Code:99705-7702
Mailing Address - Country:US
Mailing Address - Phone:907-488-8555
Mailing Address - Fax:907-488-8556
Practice Address - Street 1:167 S SANTA CLAUS LN
Practice Address - Street 2:
Practice Address - City:NORTH POLE
Practice Address - State:AK
Practice Address - Zip Code:99705-7702
Practice Address - Country:US
Practice Address - Phone:907-488-8555
Practice Address - Fax:907-488-8556
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK3692164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse