Provider Demographics
NPI:1144804550
Name:GLOUDEMANS, HOLLY ANNE
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:ANNE
Last Name:GLOUDEMANS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:ANNE
Other - Last Name:HANSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9238 PETIT AVE
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91343-3530
Mailing Address - Country:US
Mailing Address - Phone:661-803-1611
Mailing Address - Fax:
Practice Address - Street 1:1014 1/2 N VERMONT AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90029-2620
Practice Address - Country:US
Practice Address - Phone:800-576-5544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-11
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95017289207Q00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine