Provider Demographics
NPI:1992857635
Name:HOLVERSON, LAURA JEAN (RD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:JEAN
Last Name:HOLVERSON
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 1:3652 MAYER RD
Mailing Address - Street 2:
Mailing Address - City:BROWNTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53522-9604
Mailing Address - Country:US
Mailing Address - Phone:608-439-1981
Mailing Address - Fax:
Practice Address - Street 1:1045 W STEPHENSON ST
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-4864
Practice Address - Country:US
Practice Address - Phone:815-599-6677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered