Provider Demographics
NPI:1619076528
Name:KELLY, HOLLY C (MD)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:C
Last Name:KELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:7100 REDWOOD BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94945-4110
Mailing Address - Country:US
Mailing Address - Phone:415-492-1600
Mailing Address - Fax:415-492-1688
Practice Address - Street 1:7100 REDWOOD BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94945-4110
Practice Address - Country:US
Practice Address - Phone:415-492-1600
Practice Address - Fax:415-492-1688
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA72149174400000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A721493Medicare PIN