Basic Information
| Provider Information | |||||||||
| NPI: | 1912215336 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOLT | ||||||||
| FirstName: | TINA | ||||||||
| MiddleName: | MILLER | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1825 MARTHA BERRY BLVD NW | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301651625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062955331 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1060 RED BUD RD NE | ||||||||
| Address2: | |||||||||
| City: | CALHOUN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307012081 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066299507 | ||||||||
| FaxNumber: | 7066250369 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2010 | ||||||||
| LastUpdateDate: | 04/18/2013 | ||||||||
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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 | 363L00000X | RN060670 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 003109031C | 05 | GA | MEDICAID |