Provider Demographics
NPI:1285768523
Name:CAMPBELL, HOLLY ANN (RD, LD)
Entity type:Individual
Prefix:MRS
First Name:HOLLY
Middle Name:ANN
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:ANN
Other - Last Name:BUCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:217 W FAIRLANE DR
Mailing Address - Street 2:
Mailing Address - City:SAPULPA
Mailing Address - State:OK
Mailing Address - Zip Code:74066-7074
Mailing Address - Country:US
Mailing Address - Phone:405-760-7279
Mailing Address - Fax:918-512-6974
Practice Address - Street 1:4200 W MEMORIAL RD
Practice Address - Street 2:SUITE 701
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-9350
Practice Address - Country:US
Practice Address - Phone:405-755-7561
Practice Address - Fax:405-755-7615
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1423133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered