Healthcare Provider Details

I. General information

NPI: 1689756454
Provider Name (Legal Business Name): SANDRA HOLT NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SANDRA FULTON

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 08/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 EDDY ST CLAVERICK 2
PROVIDENCE RI
02903-4923
US

IV. Provider business mailing address

PO BOX 9484
PROVIDENCE RI
02940-9484
US

V. Phone/Fax

Practice location:
  • Phone: 401-854-2504
  • Fax: 401-854-2519
Mailing address:
  • Phone: 401-854-2500
  • Fax: 401-854-2519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberNPP37390
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAPRN00885
License Number StateRI
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN35082
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: