Healthcare Provider Details

I. General information

NPI: 1386389815
Provider Name (Legal Business Name): KYLE JOSEPH HOLDER FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2022
Last Update Date: 01/14/2025
Certification Date: 01/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 STATION DR STE 300
CRYSTAL LAKE IL
60014-8003
US

IV. Provider business mailing address

360 STATION DR STE 300
CRYSTAL LAKE IL
60014-8003
US

V. Phone/Fax

Practice location:
  • Phone: 815-455-1800
  • Fax: 815-455-1875
Mailing address:
  • Phone: 815-455-1800
  • Fax: 815-455-1875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209031072
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2022015229
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: