Provider Demographics
NPI:1689322026
Name:HOLDER, STACEY LYNN (CNP)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LYNN
Last Name:HOLDER
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:L
Other - Last Name:STEVENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:235 MILL ST
Mailing Address - Street 2:
Mailing Address - City:PATASKALA
Mailing Address - State:OH
Mailing Address - Zip Code:43062-8852
Mailing Address - Country:US
Mailing Address - Phone:614-795-0311
Mailing Address - Fax:
Practice Address - Street 1:1800 ALLENTOWN RD
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45805-1873
Practice Address - Country:US
Practice Address - Phone:614-795-0311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-15
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN355876163W00000X
OHCNP0032773363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse