Provider Demographics
NPI:1922037811
Name:MYLES, HOLLY NICOLE (NP)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:NICOLE
Last Name:MYLES
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:NICOLE
Other - Last Name:VICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:3750 LANDMARK DRIVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-6633
Mailing Address - Country:US
Mailing Address - Phone:765-448-4511
Mailing Address - Fax:765-447-8375
Practice Address - Street 1:3750 LANDMARK DRIVE
Practice Address - Street 2:SUITE A
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-6633
Practice Address - Country:US
Practice Address - Phone:765-448-4511
Practice Address - Fax:765-447-8375
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002110A363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000668422OtherANTHEM PROVIDER NUMBER
IN200844660Medicaid
IN000000668422OtherANTHEM PROVIDER NUMBER
INP00856470Medicare PIN
INM400019442Medicare PIN
INQ72135Medicare UPIN
INP00856470Medicare PIN