Provider Demographics
NPI:1184024325
Name:HOLMES, NATHANIEL (PT, DPT)
Entity type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:
Last Name:HOLMES
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1502 PARKVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-1821
Mailing Address - Country:US
Mailing Address - Phone:815-381-7284
Mailing Address - Fax:815-381-7281
Practice Address - Street 1:1502 PARKVIEW AVE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-1821
Practice Address - Country:US
Practice Address - Phone:815-381-7284
Practice Address - Fax:815-381-7281
Is Sole Proprietor?:No
Enumeration Date:2014-08-25
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070020824225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist