Provider Demographics
NPI:1073089934
Name:DERSE, NICOLE KRISTINA (CNC)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:KRISTINA
Last Name:DERSE
Suffix:
Gender:F
Credentials:CNC
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:JAMES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CFMP
Mailing Address - Street 1:308 E GLENDALE AVE
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-2907
Mailing Address - Country:US
Mailing Address - Phone:920-322-5115
Mailing Address - Fax:
Practice Address - Street 1:308 E GLENDALE AVE
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-2907
Practice Address - Country:US
Practice Address - Phone:920-322-5115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-18
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12D577516133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist