Healthcare Provider Details

I. General information

NPI: 1023787074
Provider Name (Legal Business Name): KELLEY D HOLLAND PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2021
Last Update Date: 04/11/2022
Certification Date: 04/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 NW COMMERCE DR
LAKE CITY FL
32055-4709
US

IV. Provider business mailing address

4240 LIRON AVE APT 103
FORT MYERS FL
33916-7868
US

V. Phone/Fax

Practice location:
  • Phone: 386-719-9000
  • Fax:
Mailing address:
  • Phone: 302-419-6173
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPAT9114916
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: