Basic Information
| Provider Information | |||||||||
| NPI: | 1851709810 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOLDERNESS | ||||||||
| FirstName: | GABLE | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 164 N BROADWAY | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543032728 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2845 GREENBRIER RD | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543116519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9202884848 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2014 | ||||||||
| LastUpdateDate: | 01/11/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 6006-33 | WI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 6006-33 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.