Provider Demographics
NPI:1609821552
Name:CANADA, BRENDA HOLT (NP)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:HOLT
Last Name:CANADA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 REXMOOR PL
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23236-3245
Mailing Address - Country:US
Mailing Address - Phone:804-330-3335
Mailing Address - Fax:804-330-9205
Practice Address - Street 1:3742 WINTERFIELD RD
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113-9238
Practice Address - Country:US
Practice Address - Phone:804-330-3335
Practice Address - Fax:804-320-9205
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024043304363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA500000906Medicare ID - Type Unspecified
VAP35568Medicare UPIN