Provider Demographics
NPI:1043541824
Name:ENDRES, NOLA LYNN (RD)
Entity type:Individual
Prefix:
First Name:NOLA
Middle Name:LYNN
Last Name:ENDRES
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:NOLA
Other - Middle Name:LYNN
Other - Last Name:HOLVERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1211 FISH HATCHERY RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715-1909
Mailing Address - Country:US
Mailing Address - Phone:608-252-8000
Mailing Address - Fax:608-260-3577
Practice Address - Street 1:1211 FISH HATCHERY RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715-1909
Practice Address - Country:US
Practice Address - Phone:608-252-8000
Practice Address - Fax:608-260-3577
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-19
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI710320133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1043541824Medicaid