Provider Demographics
NPI:1275057523
Name:HOLDER, ALEXANDRIA GRACE-MARY (PNP)
Entity Type:Individual
Prefix:
First Name:ALEXANDRIA
Middle Name:GRACE-MARY
Last Name:HOLDER
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:ALEXANDRIA
Other - Middle Name:GRACE-MARY
Other - Last Name:LOGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 850
Mailing Address - Street 2:
Mailing Address - City:ROGERSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37857-0850
Mailing Address - Country:US
Mailing Address - Phone:423-921-1600
Mailing Address - Fax:423-921-1681
Practice Address - Street 1:4307 HIGHWAY 66 S
Practice Address - Street 2:
Practice Address - City:ROGERSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37857-3155
Practice Address - Country:US
Practice Address - Phone:423-921-1600
Practice Address - Fax:423-921-1681
Is Sole Proprietor?:No
Enumeration Date:2017-07-28
Last Update Date:2017-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN22875363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics