Provider Demographics
NPI:1184194516
Name:BRIGHAM, NICOLE DIANNE (RDN, LDN)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:DIANNE
Last Name:BRIGHAM
Suffix:
Gender:F
Credentials:RDN, LDN
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:HORN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LDN
Mailing Address - Street 1:1512 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19146-1636
Mailing Address - Country:US
Mailing Address - Phone:267-239-5637
Mailing Address - Fax:267-455-0825
Practice Address - Street 1:1512 SOUTH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19146-1636
Practice Address - Country:US
Practice Address - Phone:267-239-5637
Practice Address - Fax:267-455-0825
Is Sole Proprietor?:No
Enumeration Date:2018-11-28
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN005816133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered