Healthcare Provider Details

I. General information

NPI: 1689322026
Provider Name (Legal Business Name): STACEY LYNN HOLDER CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STACEY L STEVENS CNP

II. Dates (important events)

Enumeration Date: 03/15/2022
Last Update Date: 12/07/2022
Certification Date: 12/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 ALLENTOWN RD
LIMA OH
45805-1873
US

IV. Provider business mailing address

235 MILL ST
PATASKALA OH
43062-8852
US

V. Phone/Fax

Practice location:
  • Phone: 614-795-0311
  • Fax:
Mailing address:
  • Phone: 614-795-0311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberCNP0032773
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN355876
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: