Provider Demographics
NPI:1073772984
Name:HOLT, MARY R (CPNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:R
Last Name:HOLT
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:935 BAXTER ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-2599
Mailing Address - Country:US
Mailing Address - Phone:616-456-5310
Mailing Address - Fax:616-456-8640
Practice Address - Street 1:935 BAXTER ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-2500
Practice Address - Country:US
Practice Address - Phone:616-456-5310
Practice Address - Fax:616-456-8640
Is Sole Proprietor?:No
Enumeration Date:2008-06-05
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704109296363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2742857Medicaid