Healthcare Provider Details

I. General information

NPI: 1093992885
Provider Name (Legal Business Name): HOLLY JO KELLY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2008
Last Update Date: 01/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 N WHITMAN ST
TACOMA WA
98407-1547
US

IV. Provider business mailing address

3333 N WHITMAN ST
TACOMA WA
98407-1547
US

V. Phone/Fax

Practice location:
  • Phone: 253-759-3065
  • Fax: 253-759-3075
Mailing address:
  • Phone: 253-759-3065
  • Fax: 253-759-3075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License NumberRN00114875
License Number StateWA

VIII. Authorized Official

Name: KATHY ANN OSTRANDER
Title or Position: OFFICE MANAGER
Credential:
Phone: 253-759-3065