Provider Demographics
NPI:1487424644
Name:HOLDER, MIGNON R
Entity type:Individual
Prefix:
First Name:MIGNON
Middle Name:R
Last Name:HOLDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6801 LAKE PLAZA DR STE B214
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-4068
Mailing Address - Country:US
Mailing Address - Phone:131-771-2636
Mailing Address - Fax:
Practice Address - Street 1:6801 LAKE PLAZA DR STE B214
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-4068
Practice Address - Country:US
Practice Address - Phone:131-771-2636
Practice Address - Fax:317-827-1030
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-08
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN014998253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care