Basic Information
| Provider Information | |||||||||
| NPI: | 1962924084 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOLT | ||||||||
| FirstName: | KIMBERLY | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 MICHIGAN ST NE # MC845 | ||||||||
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| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495032560 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 615 S BOWER ST | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488382614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163913139 | ||||||||
| FaxNumber: | 6163913044 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2017 | ||||||||
| LastUpdateDate: | 02/17/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 4704217795 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LG0600X | 4704217795 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
No ID Information.