Provider Demographics
NPI:1164993978
Name:SARES, NICOLE SAMANTHA
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:SAMANTHA
Last Name:SARES
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 1:3225 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:ASHTABULA
Mailing Address - State:OH
Mailing Address - Zip Code:44004-5758
Mailing Address - Country:US
Mailing Address - Phone:440-998-7515
Mailing Address - Fax:440-998-0973
Practice Address - Street 1:3225 LAKE AVE
Practice Address - Street 2:
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-5758
Practice Address - Country:US
Practice Address - Phone:440-998-7515
Practice Address - Fax:440-998-0973
Is Sole Proprietor?:No
Enumeration Date:2018-12-06
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLD.6996133V00000X
IL1049341133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered