Provider Demographics
NPI:1932503307
Name:PUDWILL, HOLLY (MS, RD, LD/N)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:PUDWILL
Suffix:
Gender:F
Credentials:MS, RD, LD/N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9428 BAYMEADOWS RD
Mailing Address - Street 2:SUITE 136
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-7969
Mailing Address - Country:US
Mailing Address - Phone:904-778-6707
Mailing Address - Fax:866-897-8749
Practice Address - Street 1:9428 BAYMEADOWS RD
Practice Address - Street 2:SUITE 136
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-7969
Practice Address - Country:US
Practice Address - Phone:904-778-6707
Practice Address - Fax:866-897-8749
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-14
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND5775133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered