Provider Demographics
NPI:1154494888
Name:HOLLAND, JO ANN (RD, LD,CDE)
Entity Type:Individual
Prefix:MRS
First Name:JO
Middle Name:ANN
Last Name:HOLLAND
Suffix:
Gender:F
Credentials:RD, LD,CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 NE LAWRIE TATUM RD
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73507-3002
Mailing Address - Country:US
Mailing Address - Phone:580-354-5240
Mailing Address - Fax:580-354-5105
Practice Address - Street 1:1515 NE LAWRIE TATUM RD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73507-3002
Practice Address - Country:US
Practice Address - Phone:580-354-5240
Practice Address - Fax:580-354-5105
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
650619133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM22671021Medicaid
8HG328Medicare PIN
320059Medicare Oscar/Certification