Healthcare Provider Details

I. General information

NPI: 1073040622
Provider Name (Legal Business Name): HOLLY KUCKELMAN RDN, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2017
Last Update Date: 05/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 UTAH ST
HIAWATHA KS
66434-2314
US

IV. Provider business mailing address

908 N 11TH ST
SENECA KS
66538-1672
US

V. Phone/Fax

Practice location:
  • Phone: 785-742-2131
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2116
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: