Provider Demographics
NPI:1942192448
Name:HOLTEN, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:HOLTEN
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 1:1408 MAPLE GROVE RD APT 206
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55811-4514
Mailing Address - Country:US
Mailing Address - Phone:218-721-8890
Mailing Address - Fax:
Practice Address - Street 1:4897 MILLER TRUNK HWY STE 121
Practice Address - Street 2:
Practice Address - City:HERMANTOWN
Practice Address - State:MN
Practice Address - Zip Code:55811-1696
Practice Address - Country:US
Practice Address - Phone:218-302-1966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-18
Last Update Date:2025-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN825764164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse