Healthcare Provider Details

I. General information

NPI: 1477917193
Provider Name (Legal Business Name): KALLIE HOLT NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2016
Last Update Date: 06/26/2024
Certification Date: 06/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W 5TH ST
DERIDDER LA
70634-4856
US

IV. Provider business mailing address

200 W 5TH ST
DERIDDER LA
70634-4856
US

V. Phone/Fax

Practice location:
  • Phone: 337-221-1417
  • Fax: 337-221-1418
Mailing address:
  • Phone: 337-202-7850
  • Fax: 337-221-1418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP08746
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: