Healthcare Provider Details

I. General information

NPI: 1578294096
Provider Name (Legal Business Name): MARIAN HOLTON-MANUEL NUTRITIONIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2022
Last Update Date: 06/24/2022
Certification Date: 06/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6401 DYLYN DR
MADISON WI
53719-4809
US

IV. Provider business mailing address

6401 DYLYN DR
MADISON WI
53719-4809
US

V. Phone/Fax

Practice location:
  • Phone: 608-335-4496
  • Fax:
Mailing address:
  • Phone: 608-335-4496
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberMSHN
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: