Provider Demographics
NPI:1023409661
Name:LONG, HOLLY (RDN, LDN)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1920 COUNTY ROAD 581
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33544-9262
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1920 COUNTY ROAD 581
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33544-9262
Practice Address - Country:US
Practice Address - Phone:813-973-4295
Practice Address - Fax:813-994-9892
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-17
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND 7317133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered