Provider Demographics
NPI:1093310229
Name:NICOL, STEPHANIE S (MS, RD, LDN, CDN)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:S
Last Name:NICOL
Suffix:
Gender:F
Credentials:MS, RD, LDN, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 OLD FITCH HILL RD APT 9
Mailing Address - Street 2:
Mailing Address - City:UNCASVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06382-1000
Mailing Address - Country:US
Mailing Address - Phone:401-363-2546
Mailing Address - Fax:
Practice Address - Street 1:24 SALT POND RD STE H5
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:RI
Practice Address - Zip Code:02879-4337
Practice Address - Country:US
Practice Address - Phone:401-360-6477
Practice Address - Fax:401-522-6062
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-04
Last Update Date:2022-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI86174930133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty