Provider Demographics
NPI:1902253164
Name:WEARE, HOLLY NICOLE (RD)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:NICOLE
Last Name:WEARE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 N SANTIAM HWY
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OR
Mailing Address - Zip Code:97355-4363
Mailing Address - Country:US
Mailing Address - Phone:541-451-7122
Mailing Address - Fax:541-451-7080
Practice Address - Street 1:525 N SANTIAM HWY
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OR
Practice Address - Zip Code:97355-4363
Practice Address - Country:US
Practice Address - Phone:541-451-7122
Practice Address - Fax:541-451-7080
Is Sole Proprietor?:No
Enumeration Date:2016-05-18
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10164585133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered