Basic Information
| Provider Information | |||||||||
| NPI: | 1114980125 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOLT | ||||||||
| FirstName: | DOROTHY | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1445 CHRISTY DR | ||||||||
| Address2: | |||||||||
| City: | JEFFERSON CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 651012853 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736367716 | ||||||||
| FaxNumber: | 5736365315 | ||||||||
| Practice Location | |||||||||
| Address1: | 525 COUCH AVE | ||||||||
| Address2: | |||||||||
| City: | KIRKWOOD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631225536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736363483 | ||||||||
| FaxNumber: | 5736365315 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2006 | ||||||||
| LastUpdateDate: | 05/02/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 080214 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 919687251 | 05 | MO | MEDICAID | P00389527 | 01 | MO | RR MEDICARE | OTHER |