Provider Demographics
NPI:1396912549
Name:HOLMAN, KIMBERLY ANNE (MT)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:ANNE
Last Name:HOLMAN
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3662
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-0662
Mailing Address - Country:US
Mailing Address - Phone:503-391-2979
Mailing Address - Fax:503-581-8389
Practice Address - Street 1:910 CAPITOL ST NE
Practice Address - Street 2:SUITE B
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-1201
Practice Address - Country:US
Practice Address - Phone:503-391-2979
Practice Address - Fax:503-581-8389
Is Sole Proprietor?:No
Enumeration Date:2008-05-15
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4760172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker