Provider Demographics
NPI:1861015232
Name:ISAAC, HOLLY
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:ISAAC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E FAIRMAN AVE
Mailing Address - Street 2:
Mailing Address - City:WATSEKA
Mailing Address - State:IL
Mailing Address - Zip Code:60970-1644
Mailing Address - Country:US
Mailing Address - Phone:815-432-7786
Mailing Address - Fax:
Practice Address - Street 1:200 E FAIRMAN AVE
Practice Address - Street 2:
Practice Address - City:WATSEKA
Practice Address - State:IL
Practice Address - Zip Code:60970-1644
Practice Address - Country:US
Practice Address - Phone:815-432-7786
Practice Address - Fax:815-432-7885
Is Sole Proprietor?:No
Enumeration Date:2020-05-20
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164006846133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered