Provider Demographics
NPI:1619514353
Name:SPATA, HOLLI A (ADP)
Entity Type:Individual
Prefix:
First Name:HOLLI
Middle Name:A
Last Name:SPATA
Suffix:
Gender:F
Credentials:ADP
Other - Prefix:
Other - First Name:HOLLI
Other - Middle Name:
Other - Last Name:RYAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3002 KING JAMES AVE
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-7832
Mailing Address - Country:US
Mailing Address - Phone:847-477-6965
Mailing Address - Fax:
Practice Address - Street 1:2130 POINT BLVD STE 900
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-9214
Practice Address - Country:US
Practice Address - Phone:888-220-6432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-02
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209019304363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209019304OtherIL STATE LIC BOARD