Provider Demographics
NPI:1669442422
Name:HOLDERNESS NAKAMURA, KRYSTAL J (MD)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:J
Last Name:HOLDERNESS NAKAMURA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-3538
Mailing Address - Country:US
Mailing Address - Phone:719-564-5544
Mailing Address - Fax:
Practice Address - Street 1:2001 LAKE AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-3538
Practice Address - Country:US
Practice Address - Phone:719-564-5544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO44146207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO26722054Medicaid
CO26722054Medicaid