Healthcare Provider Details

I. General information

NPI: 1871154922
Provider Name (Legal Business Name): MARCELLE M HOLT RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2019
Last Update Date: 06/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44200 WOODWARD AVE STE 209
PONTIAC MI
48341-5045
US

IV. Provider business mailing address

256 BLOOMFIELD BLVD
BLOOMFIELD HILLS MI
48302-0510
US

V. Phone/Fax

Practice location:
  • Phone: 248-253-0330
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704282687
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: