Provider Demographics
NPI:1285251587
Name:HOLMAN, SUSAN KEMUNTO (LVN)
Entity type:Individual
Prefix:MISS
First Name:SUSAN
Middle Name:KEMUNTO
Last Name:HOLMAN
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1314 LAKE ST STE 101
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76102-4582
Mailing Address - Country:US
Mailing Address - Phone:817-810-0660
Mailing Address - Fax:903-532-1401
Practice Address - Street 1:838 PANGBURN ST
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75051-2616
Practice Address - Country:US
Practice Address - Phone:469-223-3688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-02
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX223436164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse