Provider Demographics
NPI:1407116569
Name:HOLM, CAROL ANN (RN)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:ANN
Last Name:HOLM
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20720 SW MOUNTAIN HOME RD
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:OR
Mailing Address - Zip Code:97140-8635
Mailing Address - Country:US
Mailing Address - Phone:503-628-3766
Mailing Address - Fax:
Practice Address - Street 1:3710 SW US VETERANS HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-2964
Practice Address - Country:US
Practice Address - Phone:503-220-8262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-23
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR083037318RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse