Provider Demographics
NPI:1205169711
Name:HOLT, KELLY MAUREEN
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MAUREEN
Last Name:HOLT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:MAUREEN
Other - Last Name:RECK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:4060 4TH AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103
Mailing Address - Country:US
Mailing Address - Phone:619-718-9444
Mailing Address - Fax:619-718-9440
Practice Address - Street 1:4060 4TH AVE STE 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2120
Practice Address - Country:US
Practice Address - Phone:619-718-9444
Practice Address - Fax:619-718-9440
Is Sole Proprietor?:No
Enumeration Date:2009-09-15
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18175363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health