Basic Information
| Provider Information | |||||||||
| NPI: | 1487201091 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURNAM | ||||||||
| FirstName: | HOLLY | ||||||||
| MiddleName: | ANNE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2170 SOUTH AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH LAKE TAHOE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 961507026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305435497 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2170 SOUTH AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH LAKE TAHOE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 961507008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305413420 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2019 | ||||||||
| LastUpdateDate: | 09/08/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 766953 | CA | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 95012441 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.