Provider Demographics
NPI:1033153085
Name:HOLT, SHANNON L (MD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:L
Last Name:HOLT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-2749
Mailing Address - Country:US
Mailing Address - Phone:270-769-5963
Mailing Address - Fax:270-769-9051
Practice Address - Street 1:1115 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2749
Practice Address - Country:US
Practice Address - Phone:270-769-5963
Practice Address - Fax:270-769-9051
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY37416207VG0400X, 207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64085442Medicaid
KY0263012Medicare Oscar/Certification
KY64085442Medicaid