Provider Demographics
NPI:1063991206
Name:GATES, HOLLY ANN (NP-C)
Entity type:Individual
Prefix:MRS
First Name:HOLLY
Middle Name:ANN
Last Name:GATES
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:MRS
Other - First Name:HOLLY
Other - Middle Name:
Other - Last Name:RYDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:109 CALIFORNIA ST PO BOX 577
Mailing Address - Street 2:
Mailing Address - City:CARTERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62918-0577
Mailing Address - Country:US
Mailing Address - Phone:618-519-9200
Mailing Address - Fax:618-985-4635
Practice Address - Street 1:3111 WILLIAMSON COUNTY PKWY
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-5235
Practice Address - Country:US
Practice Address - Phone:618-519-9200
Practice Address - Fax:618-985-9155
Is Sole Proprietor?:No
Enumeration Date:2018-08-08
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL277.001378363LF0000X
IL209.017901363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily