Provider Demographics
NPI:1457725855
Name:GONZALES-GILLIGAN, HOLLY (MA, RD)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:GONZALES-GILLIGAN
Suffix:
Gender:F
Credentials:MA, RD
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:
Other - Last Name:GILLIGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, RD, CDN
Mailing Address - Street 1:10 MIRACLE MILE DR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14623-5851
Mailing Address - Country:US
Mailing Address - Phone:585-945-4278
Mailing Address - Fax:
Practice Address - Street 1:10 MIRACLE MILE DR
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623-5851
Practice Address - Country:US
Practice Address - Phone:315-945-4278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-23
Last Update Date:2025-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT86032086133V00000X
NY86032086133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC02658OtherMEDICARE YNHH