Provider Demographics
NPI:1073990362
Name:WAKE, NICOLE (MS, RD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:WAKE
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 CO RD 32A
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:NY
Mailing Address - Zip Code:13815
Mailing Address - Country:US
Mailing Address - Phone:607-373-7410
Mailing Address - Fax:607-337-4198
Practice Address - Street 1:179 N BROAD ST
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:NY
Practice Address - Zip Code:13815-1019
Practice Address - Country:US
Practice Address - Phone:607-337-4812
Practice Address - Fax:607-337-4198
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-06
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1019080133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered