Provider Demographics
NPI:1275270480
Name:WISE, HOLLY ANN (RD, LD)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:ANN
Last Name:WISE
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3466 WILLOWRUN DR APT E
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-7312
Mailing Address - Country:US
Mailing Address - Phone:509-760-6467
Mailing Address - Fax:
Practice Address - Street 1:4408 SPICEWOOD SPRINGS RD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-8504
Practice Address - Country:US
Practice Address - Phone:509-760-6467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-18
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT87266133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered