Provider Demographics
NPI:1043727993
Name:NICHOLOS, AMY JOYCE (MS, RDN ,LD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:JOYCE
Last Name:NICHOLOS
Suffix:
Gender:F
Credentials:MS, RDN ,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3980 GALLANT FOX CT
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-5416
Mailing Address - Country:US
Mailing Address - Phone:678-386-4809
Mailing Address - Fax:
Practice Address - Street 1:3980 GALLANT FOX CT
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-5416
Practice Address - Country:US
Practice Address - Phone:678-386-4809
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-01
Last Update Date:2018-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA86077822133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered