Provider Demographics
NPI:1609435304
Name:KINGERY, HOLLY (PA)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:KINGERY
Suffix:
Gender:F
Credentials:PA
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 843022
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64184-3022
Mailing Address - Country:US
Mailing Address - Phone:317-770-6900
Mailing Address - Fax:317-770-6911
Practice Address - Street 1:17600 SHAMROCK BLVD
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:IN
Practice Address - Zip Code:46074-7002
Practice Address - Country:US
Practice Address - Phone:317-214-5468
Practice Address - Fax:317-214-5469
Is Sole Proprietor?:No
Enumeration Date:2019-06-07
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10002749A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300029147Medicaid