Provider Demographics
NPI:1477917193
Name:HOLT, KALLIE (NP)
Entity Type:Individual
Prefix:
First Name:KALLIE
Middle Name:
Last Name:HOLT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:DERIDDER
Mailing Address - State:LA
Mailing Address - Zip Code:70634-4856
Mailing Address - Country:US
Mailing Address - Phone:337-202-7850
Mailing Address - Fax:
Practice Address - Street 1:1808 HIGHWAY 190 W
Practice Address - Street 2:SUITE C2
Practice Address - City:DERIDDER
Practice Address - State:LA
Practice Address - Zip Code:70634-6023
Practice Address - Country:US
Practice Address - Phone:337-348-0031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-08
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP08746363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily