Provider Demographics
NPI:1942606413
Name:HOLM, ELLEN TERESE (AGPCNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:TERESE
Last Name:HOLM
Suffix:
Gender:F
Credentials:AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3682 UTICA RIDGE RD UNIT A
Mailing Address - Street 2:
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-1648
Mailing Address - Country:US
Mailing Address - Phone:563-391-1024
Mailing Address - Fax:563-386-0965
Practice Address - Street 1:3682 UTICA RIDGE RD UNIT A
Practice Address - Street 2:
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-1648
Practice Address - Country:US
Practice Address - Phone:563-370-1853
Practice Address - Fax:563-386-0965
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-11
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN2014015805363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology