Provider Demographics
NPI:1902350556
Name:HOLBROOK, TINA (APRN)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:HOLBROOK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 PINEUR RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-9152
Mailing Address - Country:US
Mailing Address - Phone:859-200-9747
Mailing Address - Fax:
Practice Address - Street 1:312 JASON DR STE 9
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-2785
Practice Address - Country:US
Practice Address - Phone:859-626-9696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-12
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3010572363LF0000X
KY1109689163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine