Provider Demographics
NPI:1689756454
Name:HOLT, SANDRA (NP)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:HOLT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:
Other - Last Name:FULTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 9484
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02940-9484
Mailing Address - Country:US
Mailing Address - Phone:401-854-2500
Mailing Address - Fax:401-854-2519
Practice Address - Street 1:593 EDDY ST
Practice Address - Street 2:CLAVERICK 2
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4923
Practice Address - Country:US
Practice Address - Phone:401-854-2504
Practice Address - Fax:401-854-2519
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRN35082163W00000X
RINPP37390363LP0200X
RIAPRN00885363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0710890Medicaid
RI12/14/2006OtherNHPRI
RI1689756454OtherNPI
RI7058932Medicaid
RI939025129OtherRI MEDICARE GROUP NUMBER
RI007058932OtherMEDICARE
RI30578-7OtherBLUECHIP
RI413721OtherBCBSRI
RI413721OtherBCBSRI