Provider Demographics
NPI:1487201091
Name:BURNAM, HOLLY ANNE
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:ANNE
Last Name:BURNAM
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 1:2170 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-7026
Mailing Address - Country:US
Mailing Address - Phone:530-543-5497
Mailing Address - Fax:
Practice Address - Street 1:2170 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-7008
Practice Address - Country:US
Practice Address - Phone:530-541-3420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-20
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA766953163W00000X
CA95012441363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse