Provider Demographics
NPI:1174640494
Name:BUNDRANT, HOLLY MARIE (PHD, RD, LDN)
Entity Type:Individual
Prefix:DR
First Name:HOLLY
Middle Name:MARIE
Last Name:BUNDRANT
Suffix:
Gender:F
Credentials:PHD, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2087 SHIPLEY SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-7722
Mailing Address - Country:US
Mailing Address - Phone:931-528-1617
Mailing Address - Fax:
Practice Address - Street 1:225 N. WILLOW AVE.
Practice Address - Street 2:WILLOW AVE. PROFESSIONAL COMPLEX
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501
Practice Address - Country:US
Practice Address - Phone:931-528-1617
Practice Address - Fax:931-528-1617
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLDN0000001650133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered