Provider Demographics
NPI:1053965194
Name:HOLT, STACEY L
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:L
Last Name:HOLT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1224 VERNON DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45402-5714
Mailing Address - Country:US
Mailing Address - Phone:937-604-6765
Mailing Address - Fax:
Practice Address - Street 1:140 SANTA CLARA AVE APT 1
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45405-3632
Practice Address - Country:US
Practice Address - Phone:937-604-6765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-26
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH379371761200376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide