Provider Demographics
NPI:1376728139
Name:HOLSTON, DEBORAH ANN
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:ANN
Last Name:HOLSTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 LAMON ST
Mailing Address - Street 2:SUITE 218
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28301-4901
Mailing Address - Country:US
Mailing Address - Phone:910-494-8997
Mailing Address - Fax:910-568-4107
Practice Address - Street 1:111 LAMON ST
Practice Address - Street 2:SUITE 218
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-4901
Practice Address - Country:US
Practice Address - Phone:910-494-8997
Practice Address - Fax:910-568-4107
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-29
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC23409172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker