Provider Demographics
NPI:1750657128
Name:HOLLOWAY, BETTY A (RD)
Entity Type:Individual
Prefix:
First Name:BETTY
Middle Name:A
Last Name:HOLLOWAY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N57W24950 N CORPORATE CIR
Mailing Address - Street 2:PROHEALTH CARE MEDICAL ASSOCIATES INC.
Mailing Address - City:SUSSEX
Mailing Address - State:WI
Mailing Address - Zip Code:53089-4383
Mailing Address - Country:US
Mailing Address - Phone:262-820-3093
Mailing Address - Fax:262-532-9598
Practice Address - Street 1:N57W24950 N CORPORATE CIR
Practice Address - Street 2:PROHEALTH CARE MEDICAL ASSOCIATES INC.
Practice Address - City:SUSSEX
Practice Address - State:WI
Practice Address - Zip Code:53089-4383
Practice Address - Country:US
Practice Address - Phone:262-820-3093
Practice Address - Fax:262-532-9598
Is Sole Proprietor?:No
Enumeration Date:2012-03-29
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI2208133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI68375Medicare PIN