Healthcare Provider Details

I. General information

NPI: 1679900740
Provider Name (Legal Business Name): AMY MARIE HOLDER FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2013
Last Update Date: 06/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 S KINGSHIGHWAY BLVD
SAINT LOUIS MO
63110-1014
US

IV. Provider business mailing address

660 S EUCLID AVE CB 8072
SAINT LOUIS MO
63110-1010
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-9123
  • Fax: 314-747-3338
Mailing address:
  • Phone: 314-362-9123
  • Fax: 314-747-3338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2013030761
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: