Provider Demographics
NPI:1922429588
Name:HOLM, AMY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:HOLM
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 1:812 W MLK BLVD #100
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33603-3338
Mailing Address - Country:US
Mailing Address - Phone:813-224-0525
Mailing Address - Fax:813-224-0622
Practice Address - Street 1:812 W MLK BLVD #100
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33603-3338
Practice Address - Country:US
Practice Address - Phone:813-224-0525
Practice Address - Fax:813-224-0622
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-30
Last Update Date:2015-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL005843900Medicaid