Provider Demographics
NPI:1003600024
Name:HOLLIDAY, LISA NICOLE (RD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:NICOLE
Last Name:HOLLIDAY
Suffix:
Gender:
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:295 AUTUMN TRAIL WAY
Mailing Address - Street 2:
Mailing Address - City:WAVERLY HALL
Mailing Address - State:GA
Mailing Address - Zip Code:31831-2460
Mailing Address - Country:US
Mailing Address - Phone:206-355-2264
Mailing Address - Fax:
Practice Address - Street 1:295 AUTUMN TRAIL WAY
Practice Address - Street 2:
Practice Address - City:WAVERLY HALL
Practice Address - State:GA
Practice Address - Zip Code:31831-2460
Practice Address - Country:US
Practice Address - Phone:206-355-2264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-07
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD006946133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty