Provider Demographics
NPI:1295036275
Name:KELLY, HOLLIE A
Entity Type:Individual
Prefix:
First Name:HOLLIE
Middle Name:A
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OLNEY
Mailing Address - State:IL
Mailing Address - Zip Code:62450-2623
Mailing Address - Country:US
Mailing Address - Phone:618-393-7732
Mailing Address - Fax:618-395-3123
Practice Address - Street 1:905 E MAIN ST
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:IL
Practice Address - Zip Code:62450-2623
Practice Address - Country:US
Practice Address - Phone:618-393-7732
Practice Address - Fax:618-395-3123
Is Sole Proprietor?:No
Enumeration Date:2010-11-08
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041233726163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0200XNursing Service ProvidersRegistered NursePediatrics