Provider Demographics
NPI:1083306542
Name:NIKODYM, HOLLY LYNN (FNP)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:LYNN
Last Name:NIKODYM
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 SAN BERNARDINO RD STE 300
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-7299
Mailing Address - Country:US
Mailing Address - Phone:909-579-6753
Mailing Address - Fax:
Practice Address - Street 1:901 SAN BERNARDINO RD STE 300
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-7299
Practice Address - Country:US
Practice Address - Phone:909-579-6753
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-23
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95025306363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily