Provider Demographics
NPI:1518669803
Name:HOLT, STACEY ARLENE (APRN)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:ARLENE
Last Name:HOLT
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:
Other - Last Name:HICKERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:107 NORTHSIDE LN
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37160-2348
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2835 U.S. 231
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37160
Practice Address - Country:US
Practice Address - Phone:931-685-5433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-20
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN33049363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily