Provider Demographics
NPI:1417363490
Name:HOLAHAN, KIMBERLY BROCK (MNS, RDN, LD, RN)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:BROCK
Last Name:HOLAHAN
Suffix:
Gender:F
Credentials:MNS, RDN, LD, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 UNIVERSITY RDG
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-3635
Mailing Address - Country:US
Mailing Address - Phone:864-372-3269
Mailing Address - Fax:864-282-4203
Practice Address - Street 1:200 UNIVERSITY RDG
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29601-3635
Practice Address - Country:US
Practice Address - Phone:864-372-3269
Practice Address - Fax:864-282-4203
Is Sole Proprietor?:No
Enumeration Date:2014-07-10
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC108133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered