Provider Demographics
NPI:1730458530
Name:HOLT, TRACY RYAN (APRN)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:RYAN
Last Name:HOLT
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:200 E CHESTNUT ST STE 303
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1831
Practice Address - Country:US
Practice Address - Phone:502-629-5552
Practice Address - Fax:502-629-3132
Is Sole Proprietor?:No
Enumeration Date:2011-12-22
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3007211363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000749568OtherANTHEM - NIS
IN201062930Medicaid
KY7100199570Medicaid
KY13274OtherSIHO - NICS
KY50038648OtherPASSPORT - NIS
KY7100199570Medicaid