Provider Demographics
NPI:1619076528
Name:KELLY, HOLLY C (MD)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:C
Last Name:KELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 276950
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-6950
Mailing Address - Country:US
Mailing Address - Phone:866-681-0738
Mailing Address - Fax:916-854-6769
Practice Address - Street 1:101 ROWLAND WAY
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94945-5008
Practice Address - Country:US
Practice Address - Phone:415-866-9145
Practice Address - Fax:415-366-7535
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA72149174400000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A721493Medicare PIN