Provider Demographics
NPI:1164631669
Name:HOLT, MELISSA RAE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:RAE
Last Name:HOLT
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8420 WILLIAMS RD
Mailing Address - Street 2:
Mailing Address - City:CHARDON
Mailing Address - State:OH
Mailing Address - Zip Code:44024-9210
Mailing Address - Country:US
Mailing Address - Phone:440-286-7656
Mailing Address - Fax:
Practice Address - Street 1:8420 WILLIAMS RD
Practice Address - Street 2:
Practice Address - City:CHARDON
Practice Address - State:OH
Practice Address - Zip Code:44024-9210
Practice Address - Country:US
Practice Address - Phone:440-286-7656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.087910-MEDS164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2124445Medicaid