Healthcare Provider Details

I. General information

NPI: 1144215393
Provider Name (Legal Business Name): DONNA CAROL HOLT - COSTAIN APRN,BC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/14/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 JUNGERMANN CIR SUITE 101
ST PETERS MO
63376-1622
US

IV. Provider business mailing address

70 JUNGERMANN CIR SUITE 101
ST PETERS MO
63376-1622
US

V. Phone/Fax

Practice location:
  • Phone: 636-926-0404
  • Fax: 636-939-3218
Mailing address:
  • Phone: 636-926-0404
  • Fax: 636-939-3218

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2000168672
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: