Provider Demographics
NPI:1114129046
Name:BARRETT, NIKOLE SUZANNE (RDN, CD)
Entity Type:Individual
Prefix:MRS
First Name:NIKOLE
Middle Name:SUZANNE
Last Name:BARRETT
Suffix:
Gender:F
Credentials:RDN, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229 E OMER AVE
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-6345
Mailing Address - Country:US
Mailing Address - Phone:574-217-8372
Mailing Address - Fax:
Practice Address - Street 1:229 E OMER AVE
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-6345
Practice Address - Country:US
Practice Address - Phone:574-217-8372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-04
Last Update Date:2014-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37001744A133VN1005X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
Provider Identifiers
StateIdentifier IDID TypeIssuer
INPENDINGMedicare ID - Type Unspecified