MEDICARE: KEISHALEI HOLT RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WC1500X	Community Health Registered Nurse	11822477-3102	UT
2	163WH0200X	Home Health Registered Nurse	11822477-3102	UT

General Provider Information

NPI Number	:	1598469173
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEISHALEI HOLT RN

Provider Business Mailing Address
First Line	:	273 E 1850 N UNIT 40
Second Line	:
City	:	NORTH OGDEN
State	:	UT
Zip	:	84414-3099
Country	:	US
Telephone Number	:	435-919-6556
Fax Number	:

Provider Business Practice Location Address
First Line	:	2830 S REDWOOD RD STE A
Second Line	:
City	:	WEST VALLEY CITY
State	:	UT
Zip	:	84119-5626
Country	:	US
Telephone Number	:	385-303-4592
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/28/2023
Last Update Date	:	03/28/2023

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