Provider Demographics
NPI:1063860997
Name:HOLLAND, JOELLE
Entity Type:Individual
Prefix:
First Name:JOELLE
Middle Name:
Last Name:HOLLAND
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 1:170 WESTFALEN TRL
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55340-4621
Mailing Address - Country:US
Mailing Address - Phone:763-478-3505
Mailing Address - Fax:
Practice Address - Street 1:170 WESTFALEN TRL
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:MN
Practice Address - Zip Code:55340-4621
Practice Address - Country:US
Practice Address - Phone:763-478-3505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-01
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3470152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1063860997Medicaid