Healthcare Provider Details

I. General information

NPI: 1003600024
Provider Name (Legal Business Name): LISA NICOLE HOLLIDAY RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2025
Last Update Date: 04/07/2025
Certification Date: 04/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

295 AUTUMN TRAIL WAY
WAVERLY HALL GA
31831-2460
US

IV. Provider business mailing address

295 AUTUMN TRAIL WAY
WAVERLY HALL GA
31831-2460
US

V. Phone/Fax

Practice location:
  • Phone: 206-355-2264
  • Fax:
Mailing address:
  • Phone: 206-355-2264
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD006946
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: