Basic Information
| Provider Information | |||||||||
| NPI: | 1700264975 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENRY | ||||||||
| FirstName: | HOLLY | ||||||||
| MiddleName: | JO | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | R.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HANCOCK | ||||||||
| OtherFirstName: | HOLLY | ||||||||
| OtherMiddleName: | JO | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | R.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 400 HEALTH PARK BLVD. | ||||||||
| Address2: | |||||||||
| City: | ST. AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32086 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048195155 | ||||||||
| FaxNumber: | 9048194936 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 HEALTH PARK BLVD. | ||||||||
| Address2: | |||||||||
| City: | ST. AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32086 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048195155 | ||||||||
| FaxNumber: | 9048194936 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2015 | ||||||||
| LastUpdateDate: | 05/08/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | ND5989 | FL | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.