Healthcare Provider Details

I. General information

NPI: 1982244968
Provider Name (Legal Business Name): KELLY A HOLMES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2020
Last Update Date: 05/15/2025
Certification Date: 05/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22001 JAMAICA AVE
QUEENS VILLAGE NY
11428-2140
US

IV. Provider business mailing address

12 BROOKLYN AVE APT 501
VALLEY STREAM NY
11581-1287
US

V. Phone/Fax

Practice location:
  • Phone: 718-412-1848
  • Fax:
Mailing address:
  • Phone: 929-404-1011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code247ZC0005X
TaxonomyClinical Laboratory Director (Non-physician)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: