Basic Information
Provider Information | |||||||||
NPI: | 1609871110 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HOLLAND | ||||||||
FirstName: | LORRETTA | ||||||||
MiddleName: | R | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | RHODES | ||||||||
OtherFirstName: | LORETTA | ||||||||
OtherMiddleName: | J | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | NP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 5900 LAKE WRIGHT DR | ||||||||
Address2: | SUITE 300 | ||||||||
City: | NORFOLK | ||||||||
State: | VA | ||||||||
PostalCode: | 235021871 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7572135700 | ||||||||
FaxNumber: | 7572135701 | ||||||||
Practice Location | |||||||||
Address1: | 300 MEDICAL PARKWAY | ||||||||
Address2: | SUITE 314 | ||||||||
City: | CHESAPEAKE | ||||||||
State: | VA | ||||||||
PostalCode: | 233204985 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7575494403 | ||||||||
FaxNumber: | 7575494332 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/21/2005 | ||||||||
LastUpdateDate: | 06/03/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 0024128931 | VA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 007792476 | 05 | VA |   | MEDICAID | 1609871110 | 05 | VA |   | MEDICAID | 1002186N | 01 | VA | OPTIMA | OTHER |