Provider Demographics
NPI:1952495046
Name:HOLMAN, VICTORIA (RN,ANP)
Entity Type:Individual
Prefix:MS
First Name:VICTORIA
Middle Name:
Last Name:HOLMAN
Suffix:
Gender:F
Credentials:RN,ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 MASON RIDGE CENTER DR
Mailing Address - Street 2:STE 300
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8573
Mailing Address - Country:US
Mailing Address - Phone:314-725-2010
Mailing Address - Fax:314-725-0709
Practice Address - Street 1:3009 N BALLAS RD
Practice Address - Street 2:SUITE 102B
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2322
Practice Address - Country:US
Practice Address - Phone:314-725-2010
Practice Address - Fax:314-725-0709
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO121611363LA2200X, 363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1952495046Medicaid
MO425299336Medicaid
MO1952495046Medicaid
MO005012262Medicare PIN
MO147400030Medicare PIN