Healthcare Provider Details

I. General information

NPI: 1205173648
Provider Name (Legal Business Name): HOLLY J NILES M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2013
Last Update Date: 08/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

89 LANCASTER RD SUITE 9
WEST HARTFORD CT
06119-1525
US

IV. Provider business mailing address

89 LANCASTER RD SUITE 9
WEST HARTFORD CT
06119-1525
US

V. Phone/Fax

Practice location:
  • Phone: 860-266-5866
  • Fax:
Mailing address:
  • Phone: 860-266-5866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: