Healthcare Provider Details

I. General information

NPI: 1053448134
Provider Name (Legal Business Name): PHYLLIS ANN HOLMES RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 06/21/2022
Certification Date: 06/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 MEADOWLANDS PKWY
SECAUCUS NJ
07094-2977
US

IV. Provider business mailing address

130 OVERLOOK AVE APT 3K
HACKENSACK NJ
07601-2234
US

V. Phone/Fax

Practice location:
  • Phone: 888-369-5550
  • Fax: 888-369-5550
Mailing address:
  • Phone: 888-369-5550
  • Fax: 888-369-5550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number886131
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: