Provider Demographics
NPI:1114428026
Name:ENDO, HOLLY M (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:HOLLY
Middle Name:M
Last Name:ENDO
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3877
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60434-3877
Mailing Address - Country:US
Mailing Address - Phone:815-714-7171
Mailing Address - Fax:
Practice Address - Street 1:905 CLINGAN RIDGE DR NW
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37312-3729
Practice Address - Country:US
Practice Address - Phone:423-476-6166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-26
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN23920363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1114428026Medicaid