Provider Demographics
NPI:1801435052
Name:HOLT, REBECCA ELIZABETH (APRN)
Entity type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:ELIZABETH
Last Name:HOLT
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MS
Other - First Name:REBECCA
Other - Middle Name:ELIZABETH
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:501 NW LITTLE AVE
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64063-2135
Mailing Address - Country:US
Mailing Address - Phone:816-517-1142
Mailing Address - Fax:
Practice Address - Street 1:7405 RENNER RD
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:KS
Practice Address - Zip Code:66217-9414
Practice Address - Country:US
Practice Address - Phone:913-588-8450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-04
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QU0200X
KS53-78887-112207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Single Specialty