Basic Information
| Provider Information | |||||||||
| NPI: | 1235512195 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOLEMAN | ||||||||
| FirstName: | AUDRA | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BECHT | ||||||||
| OtherFirstName: | AUDRA | ||||||||
| OtherMiddleName: | B | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1643 NW 136TH AVE | ||||||||
| Address2: | BLDG H STE 100 MSC 11607-0004 | ||||||||
| City: | SUNRISE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333232857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655001346 | ||||||||
| FaxNumber: | 8655607110 | ||||||||
| Practice Location | |||||||||
| Address1: | 421 CHESTNUT ST | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477131227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124507466 | ||||||||
| FaxNumber: | 8124504665 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2015 | ||||||||
| LastUpdateDate: | 11/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 28197688A | IN | N | Nursing Service Providers | Registered Nurse | 363L00000X | 1029833 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 71005756A | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 201319420 | 05 | IN | MEDICAID |