Provider Demographics
NPI:1679147839
Name:MELVIN, HOLLY ANN (NBC-HWC)
Entity type:Individual
Prefix:MRS
First Name:HOLLY
Middle Name:ANN
Last Name:MELVIN
Suffix:
Gender:F
Credentials:NBC-HWC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 AURELIA DR
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-5021
Mailing Address - Country:US
Mailing Address - Phone:618-969-0634
Mailing Address - Fax:
Practice Address - Street 1:1205 AURELIA DR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-5021
Practice Address - Country:US
Practice Address - Phone:618-969-0634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-13
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA-3387622