Provider Demographics
NPI:1073230660
Name:NIKITIN, MOLLY
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:NIKITIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9801 NE 124TH ST
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-3713
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4363 TRILLIUM LN NW
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98312-9564
Practice Address - Country:US
Practice Address - Phone:630-549-5371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-24
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86295817133V00000X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered