Healthcare Provider Details

I. General information

NPI: 1073772984
Provider Name (Legal Business Name): MARY R. HOLT CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2008
Last Update Date: 06/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

935 BAXTER ST SE
GRAND RAPIDS MI
49506-2500
US

IV. Provider business mailing address

935 BAXTER ST SE
GRAND RAPIDS MI
49506-2599
US

V. Phone/Fax

Practice location:
  • Phone: 616-456-5310
  • Fax: 616-456-8640
Mailing address:
  • Phone: 616-456-5310
  • Fax: 616-456-8640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number4704109296
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: