Provider Demographics
NPI:1043719834
Name:NICHOLSON, VALERIE (RD, LD)
Entity Type:Individual
Prefix:
First Name:VALERIE
Middle Name:
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:VALERIE
Other - Middle Name:
Other - Last Name:BROESTL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LD
Mailing Address - Street 1:4200 STORY RD
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW PARK
Mailing Address - State:OH
Mailing Address - Zip Code:44126-1750
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25550 CHARGRIN BLVD
Practice Address - Street 2:STE 200
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122
Practice Address - Country:US
Practice Address - Phone:216-765-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-07
Last Update Date:2018-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLD.7369133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered