=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336817469
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HOLLY ANN HERZFELD-VAN DYKE RD,MS,LD,CDE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/02/2021
-----------------------------------------------------
Last Update Date | 02/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3230-1 LIZZY LANE
-----------------------------------------------------
City | CONWAY
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-818-9060
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1811
-----------------------------------------------------
City | CONWAY
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72033-1811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-818-9060
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133VN1006X
-----------------------------------------------------
Taxonomy Name | Metabolic Nutrition Registered Dietitian
-----------------------------------------------------
License Number | 0783
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------