Provider Demographics
NPI:1033569330
Name:ANGUILM, NICHOLE (RDN)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:ANGUILM
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:NICHOLE
Other - Middle Name:
Other - Last Name:SNYDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6943 E EARLL DR APT 6
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251-6877
Mailing Address - Country:US
Mailing Address - Phone:231-670-6772
Mailing Address - Fax:
Practice Address - Street 1:3830 E VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-6920
Practice Address - Country:US
Practice Address - Phone:602-243-7277
Practice Address - Fax:602-286-0808
Is Sole Proprietor?:No
Enumeration Date:2016-06-16
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ86053094133V00000X
MI86053094133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ173596Medicaid