Provider Demographics
NPI:1700264975
Name:HENRY, HOLLY JO (RD)
Entity Type:Individual
Prefix:MRS
First Name:HOLLY
Middle Name:JO
Last Name:HENRY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:MISS
Other - First Name:HOLLY
Other - Middle Name:JO
Other - Last Name:HANCOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:400 HEALTH PARK BLVD.
Mailing Address - Street 2:
Mailing Address - City:ST. AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086
Mailing Address - Country:US
Mailing Address - Phone:904-819-5155
Mailing Address - Fax:904-819-4936
Practice Address - Street 1:400 HEALTH PARK BLVD.
Practice Address - Street 2:
Practice Address - City:ST. AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086
Practice Address - Country:US
Practice Address - Phone:904-819-5155
Practice Address - Fax:904-819-4936
Is Sole Proprietor?:No
Enumeration Date:2015-05-08
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND5989133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered