Provider Demographics
NPI:1053831214
Name:VANNITAMBY, HOLLY (DO)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:VANNITAMBY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 MAIN ST STE A
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61602-1080
Mailing Address - Country:US
Mailing Address - Phone:309-672-4977
Mailing Address - Fax:
Practice Address - Street 1:6339 N BIG HOLLOW RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-2907
Practice Address - Country:US
Practice Address - Phone:309-693-3315
Practice Address - Fax:309-693-9385
Is Sole Proprietor?:No
Enumeration Date:2017-06-20
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036150954207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
125.071177OtherLICENSE
IL036.150954Medicaid