1518023167 NPI number — DIANA E HOLT PNP

Table of content: DIANA E HOLT PNP (NPI 1518023167)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518023167 NPI number — DIANA E HOLT PNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOLT
Provider First Name:
DIANA
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1518023167
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/28/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
107 E OAK AVE
Provider Second Line Business Mailing Address:
101
Provider Business Mailing Address City Name:
FLAGSTAFF
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86001-1818
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-913-8808
Provider Business Mailing Address Fax Number:
928-913-8875

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5130 N US HIGHWAY 89
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLAGSTAFF
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86004-2837
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-773-2054
Provider Business Practice Location Address Fax Number:
928-773-2286
Provider Enumeration Date:
12/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0200X , with the licence number:  RN083858 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 198970 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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