Provider Demographics
NPI:1073040622
Name:KUCKELMAN, HOLLY (RDN, LD)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:KUCKELMAN
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:908 N 11TH ST
Mailing Address - Street 2:
Mailing Address - City:SENECA
Mailing Address - State:KS
Mailing Address - Zip Code:66538-1672
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 UTAH ST
Practice Address - Street 2:
Practice Address - City:HIAWATHA
Practice Address - State:KS
Practice Address - Zip Code:66434-2314
Practice Address - Country:US
Practice Address - Phone:785-742-2131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-15
Last Update Date:2017-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2116133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered