Provider Demographics
NPI:1598042145
Name:HOLM, ROXANE LYNN (PMHNP)
Entity Type:Individual
Prefix:
First Name:ROXANE
Middle Name:LYNN
Last Name:HOLM
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 S MAIN ST STE 400
Mailing Address - Street 2:
Mailing Address - City:VIROQUA
Mailing Address - State:WI
Mailing Address - Zip Code:54665-4000
Mailing Address - Country:US
Mailing Address - Phone:608-637-3174
Mailing Address - Fax:608-638-5038
Practice Address - Street 1:407 S MAIN ST STE 400
Practice Address - Street 2:
Practice Address - City:VIROQUA
Practice Address - State:WI
Practice Address - Zip Code:54665-4000
Practice Address - Country:US
Practice Address - Phone:608-637-3174
Practice Address - Fax:608-638-5038
Is Sole Proprietor?:No
Enumeration Date:2011-11-10
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5690363L00000X, 363LP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner