Healthcare Provider Details

I. General information

NPI: 1477090041
Provider Name (Legal Business Name): DR. SHELLEY HOLT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2017
Last Update Date: 01/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17573 CHERVIL LN
SAN BERNARDINO CA
92407-9068
US

IV. Provider business mailing address

17573 CHERVIL LN
SAN BERNARDINO CA
92407-9068
US

V. Phone/Fax

Practice location:
  • Phone: 909-544-6482
  • Fax:
Mailing address:
  • Phone: 909-544-6482
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code405300000X
TaxonomyPrevention Professional
License Number0000000
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: