Healthcare Provider Details

I. General information

NPI: 1407771058
Provider Name (Legal Business Name): MARIAH CARLY HOLST NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2026
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2790 GODWIN BLVD STE 360
SUFFOLK VA
23434-8153
US

IV. Provider business mailing address

2790 GODWIN BLVD STE 360
SUFFOLK VA
23434-8153
US

V. Phone/Fax

Practice location:
  • Phone: 757-261-8070
  • Fax: 757-995-7095
Mailing address:
  • Phone: 757-261-8070
  • Fax: 757-995-7095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number0024198442
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number0024198442
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number0024198442
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: