Provider Demographics
NPI:1215045109
Name:HOLT, JEANA MARIE (APNP)
Entity Type:Individual
Prefix:MRS
First Name:JEANA
Middle Name:MARIE
Last Name:HOLT
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12060 W WHITAKER AVE
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53228-2474
Mailing Address - Country:US
Mailing Address - Phone:414-545-0901
Mailing Address - Fax:
Practice Address - Street 1:12060 W WHITAKER AVE
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53228-2474
Practice Address - Country:US
Practice Address - Phone:414-545-0901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI127716-030363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI127716-030OtherNURSING STATE LICENSE NUM