Provider Demographics
NPI:1750630786
Name:KELLY, HOLLY R (NP)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:R
Last Name:KELLY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:R
Other - Last Name:SUCHARETZA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:211 N EDDY ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2808
Mailing Address - Country:US
Mailing Address - Phone:574-237-9231
Mailing Address - Fax:574-204-6355
Practice Address - Street 1:211 N EDDY ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-2808
Practice Address - Country:US
Practice Address - Phone:574-237-9231
Practice Address - Fax:574-204-6355
Is Sole Proprietor?:No
Enumeration Date:2012-09-06
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71004121A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201092360Medicaid
IN146470002Medicare PIN