Provider Demographics
NPI:1780276485
Name:HOLT, MAYBELLE (NP)
Entity type:Individual
Prefix:
First Name:MAYBELLE
Middle Name:
Last Name:HOLT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8717 DROEGE RD
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IN
Mailing Address - Zip Code:46733-9609
Mailing Address - Country:US
Mailing Address - Phone:760-696-0095
Mailing Address - Fax:
Practice Address - Street 1:205 TOWER DR
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:IN
Practice Address - Zip Code:46772-9362
Practice Address - Country:US
Practice Address - Phone:260-692-6163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-04
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71010817A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily