Healthcare Provider Details

I. General information

NPI: 1609552462
Provider Name (Legal Business Name): STACIE HOLT RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2023
Last Update Date: 06/26/2023
Certification Date: 06/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2044 MESA PALMS DR
ST GEORGE UT
84770-5546
US

IV. Provider business mailing address

2044 MESA PALMS DR
ST GEORGE UT
84770-5546
US

V. Phone/Fax

Practice location:
  • Phone: 435-668-2023
  • Fax:
Mailing address:
  • Phone: 435-668-2023
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number7518994-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: