Provider Demographics
NPI:1376121848
Name:HOLDEMAN, VICTORIA S
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:S
Last Name:HOLDEMAN
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 1:4311 E 65TH S
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83406-8127
Mailing Address - Country:US
Mailing Address - Phone:208-970-2027
Mailing Address - Fax:
Practice Address - Street 1:4311 E 65TH S
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83406-8127
Practice Address - Country:US
Practice Address - Phone:208-970-2027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-29
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID57304363LP0808X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered Nurse