Healthcare Provider Details

I. General information

NPI: 1750630786
Provider Name (Legal Business Name): HOLLY R. KELLY N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HOLLY R. SUCHARETZA

II. Dates (important events)

Enumeration Date: 09/06/2012
Last Update Date: 12/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 N EDDY ST
SOUTH BEND IN
46617-2808
US

IV. Provider business mailing address

211 N EDDY ST
SOUTH BEND IN
46617-2808
US

V. Phone/Fax

Practice location:
  • Phone: 574-237-9231
  • Fax: 574-204-6355
Mailing address:
  • Phone: 574-237-9231
  • Fax: 574-204-6355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71004121A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: