Provider Demographics
NPI:1093160970
Name:NICHOLS, BRANDON L (RD, CSSD)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:L
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:RD, CSSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9005 S BRYERLY CT
Mailing Address - Street 2:
Mailing Address - City:HEREFORD
Mailing Address - State:AZ
Mailing Address - Zip Code:85615-8419
Mailing Address - Country:US
Mailing Address - Phone:520-249-1599
Mailing Address - Fax:
Practice Address - Street 1:9005 S BRYERLY CT
Practice Address - Street 2:
Practice Address - City:HEREFORD
Practice Address - State:AZ
Practice Address - Zip Code:85615-8419
Practice Address - Country:US
Practice Address - Phone:520-249-1599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-28
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered