Provider Demographics
NPI:1922037811
Name:MYLES, HOLLY NICOLE (NP)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:NICOLE
Last Name:MYLES
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:NICOLE
Other - Last Name:VICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-6633
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:118 W DREXEL PKWY
Practice Address - Street 2:
Practice Address - City:RENSSELAER
Practice Address - State:IN
Practice Address - Zip Code:47978-7344
Practice Address - Country:US
Practice Address - Phone:219-866-4300
Practice Address - Fax:219-866-7591
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002110A363LA2100X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000668422OtherANTHEM PROVIDER NUMBER
IN200844660Medicaid
IN000000668422OtherANTHEM PROVIDER NUMBER
INP00856470Medicare PIN
INM400019442Medicare PIN
INQ72135Medicare UPIN
INP00856470Medicare PIN