Basic Information
| Provider Information | |||||||||
| NPI: | 1285251587 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOLMAN | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | KEMUNTO | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | LVN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1314 LAKE ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761024582 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8178100660 | ||||||||
| FaxNumber: | 9035321401 | ||||||||
| Practice Location | |||||||||
| Address1: | 838 PANGBURN ST | ||||||||
| Address2: | |||||||||
| City: | GRAND PRAIRIE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750512616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4692233688 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2020 | ||||||||
| LastUpdateDate: | 07/02/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164X00000X | 223436 | TX | Y | Nursing Service Providers | Licensed Vocational Nurse |
No ID Information.