Provider Demographics
NPI:1528590577
Name:STORM, HOLLY D (DO)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:D
Last Name:STORM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:D
Other - Last Name:KOFELDT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:395 WESTFIELD RD STE B
Mailing Address - Street 2:
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46060-1425
Mailing Address - Country:US
Mailing Address - Phone:317-773-0760
Mailing Address - Fax:317-776-7134
Practice Address - Street 1:8414 NAAB RD
Practice Address - Street 2:SUITE 210
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1972
Practice Address - Country:US
Practice Address - Phone:317-338-7510
Practice Address - Fax:317-338-7540
Is Sole Proprietor?:No
Enumeration Date:2017-03-29
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02006320A207V00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN02006320AMedicaid