Provider Demographics
NPI:1326073446
Name:YEATTS, HOLLY (NP)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:YEATTS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 KIRTS BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-4135
Mailing Address - Country:US
Mailing Address - Phone:248-434-6169
Mailing Address - Fax:855-618-6655
Practice Address - Street 1:2132 E 3RD ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45403-1991
Practice Address - Country:US
Practice Address - Phone:937-528-6850
Practice Address - Fax:937-528-6810
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP07594363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2623316Medicaid
OHQ71321Medicare UPIN
OHH115550Medicare PIN
OH2623316Medicaid