MEDICARE: STACIE 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	163WP0200X	Pediatric Registered Nurse	7518994-3102	UT

General Provider Information

NPI Number	:	1609552462
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACIE HOLT RN

Provider Business Mailing Address
First Line	:	2044 MESA PALMS DR
Second Line	:
City	:	ST GEORGE
State	:	UT
Zip	:	84770-5546
Country	:	US
Telephone Number	:	435-668-2023
Fax Number	:

Provider Business Practice Location Address
First Line	:	2044 MESA PALMS DR
Second Line	:
City	:	ST GEORGE
State	:	UT
Zip	:	84770-5546
Country	:	US
Telephone Number	:	435-668-2023
Fax Number	:

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

Provider Enumeration Date	:	06/26/2023
Last Update Date	:	06/26/2023

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