Provider Demographics
NPI:1891937587
Name:KELLIS, HOLLY RAE (LPN)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:RAE
Last Name:KELLIS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1414 GROVER ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45505-3925
Mailing Address - Country:US
Mailing Address - Phone:937-206-1897
Mailing Address - Fax:
Practice Address - Street 1:1414 GROVER ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45505-3925
Practice Address - Country:US
Practice Address - Phone:937-206-1897
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-27
Last Update Date:2009-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN113181164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse