Healthcare Provider Details

I. General information

NPI: 1336817469
Provider Name (Legal Business Name): HOLLY ANN HERZFELD-VAN DYKE RD,MS,LD,CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2021
Last Update Date: 02/18/2022
Certification Date: 02/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3230-1 LIZZY LANE
CONWAY AR
72032
US

IV. Provider business mailing address

PO BOX 1811
CONWAY AR
72033-1811
US

V. Phone/Fax

Practice location:
  • Phone: 501-818-9060
  • Fax:
Mailing address:
  • Phone: 501-818-9060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number0783
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: