Provider Demographics
NPI:1518697770
Name:HOLDER, KANISA LANEE
Entity Type:Individual
Prefix:
First Name:KANISA
Middle Name:LANEE
Last Name:HOLDER
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 1:245 ANCHOR WAY
Mailing Address - Street 2:
Mailing Address - City:UNIONDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11553-1303
Mailing Address - Country:US
Mailing Address - Phone:516-304-0768
Mailing Address - Fax:
Practice Address - Street 1:245 ANCHOR WAY
Practice Address - Street 2:
Practice Address - City:UNIONDALE
Practice Address - State:NY
Practice Address - Zip Code:11553-1303
Practice Address - Country:US
Practice Address - Phone:516-304-0768
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-12
Last Update Date:2022-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle