Provider Demographics
NPI:1144878612
Name:HOLDER, ELLMAN BARKLEY (RN)
Entity type:Individual
Prefix:
First Name:ELLMAN
Middle Name:BARKLEY
Last Name:HOLDER
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 GULICK ST
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:IN
Mailing Address - Zip Code:46938-1242
Mailing Address - Country:US
Mailing Address - Phone:765-860-6769
Mailing Address - Fax:
Practice Address - Street 1:3500 S LAFOUNTAIN ST
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-3803
Practice Address - Country:US
Practice Address - Phone:765-776-8444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-28
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28187323A163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WE0003XNursing Service ProvidersRegistered NurseEmergency