Provider Demographics
NPI:1235906496
Name:HOLMES, MELISSA (RSA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:HOLMES
Suffix:
Gender:F
Credentials:RSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19015 S JODI RD STE H
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-8534
Mailing Address - Country:US
Mailing Address - Phone:708-995-5418
Mailing Address - Fax:832-804-8886
Practice Address - Street 1:19015 S JODI RD STE H
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-8534
Practice Address - Country:US
Practice Address - Phone:708-995-5418
Practice Address - Fax:832-804-8886
Is Sole Proprietor?:No
Enumeration Date:2023-12-07
Last Update Date:2023-12-07
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
COSA.0003122OtherCOLORADO DEPARTMENT OF REGULATORY AGENCIES