Provider Demographics
NPI:1639257595
Name:KELLY, HOLLY JO (RNFA CNOR)
Entity Type:Individual
Prefix:MRS
First Name:HOLLY
Middle Name:JO
Last Name:KELLY
Suffix:
Gender:F
Credentials:RNFA CNOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 N WHITMAN ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98407-1547
Mailing Address - Country:US
Mailing Address - Phone:253-759-3065
Mailing Address - Fax:253-759-3075
Practice Address - Street 1:520 N 4TH AVE
Practice Address - Street 2:
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-5257
Practice Address - Country:US
Practice Address - Phone:509-546-2203
Practice Address - Fax:509-546-2262
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA025801 RN00114875163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9632084Medicaid