Provider Demographics
NPI:1518023167
Name:HOLT, DIANA E (PNP)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:E
Last Name:HOLT
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 E OAK AVE
Mailing Address - Street 2:101
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-1818
Mailing Address - Country:US
Mailing Address - Phone:928-913-8808
Mailing Address - Fax:928-913-8875
Practice Address - Street 1:107 E OAK AVE
Practice Address - Street 2:101
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-1818
Practice Address - Country:US
Practice Address - Phone:928-913-8808
Practice Address - Fax:928-913-8875
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN083858363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ198970Medicaid
NPP000Medicare UPIN