Healthcare Provider Details

I. General information

NPI: 1952173916
Provider Name (Legal Business Name): HOLLY R LEWIS RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2023
Last Update Date: 10/27/2023
Certification Date: 10/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 DIVISION ST
BALTIMORE MD
21217-3121
US

IV. Provider business mailing address

1459 HUDSON VIEW RD
ESSEX MD
21221-1651
US

V. Phone/Fax

Practice location:
  • Phone: 410-383-8300
  • Fax: 410-383-3160
Mailing address:
  • Phone: 443-527-1455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86040950
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDX4281
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: