Provider Demographics
NPI:1376090977
Name:HOLLAND, AUDREY
Entity Type:Individual
Prefix:
First Name:AUDREY
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 1:2965 E 109TH AVE
Mailing Address - Street 2:
Mailing Address - City:NORTHGLENN
Mailing Address - State:CO
Mailing Address - Zip Code:80233-5475
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2965 EAST 109TH AVENUE
Practice Address - Street 2:SPECIALTY FOOT CARE LLC
Practice Address - City:NORTHGLENN
Practice Address - State:CO
Practice Address - Zip Code:80233
Practice Address - Country:US
Practice Address - Phone:303-980-0015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0109418163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse