Provider Demographics
NPI:1194458794
Name:KEDDINGTON, HOLLY (PA-C)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:KEDDINGTON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 HIGHLAND TER
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:WI
Mailing Address - Zip Code:53594-2217
Mailing Address - Country:US
Mailing Address - Phone:920-478-2141
Mailing Address - Fax:920-478-3820
Practice Address - Street 1:105 HIGHLAND TER
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:WI
Practice Address - Zip Code:53594-2217
Practice Address - Country:US
Practice Address - Phone:920-478-2141
Practice Address - Fax:920-478-3820
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-01
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7947-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1194458794Medicaid