Provider Demographics
NPI:1194394510
Name:NISSEN, DAVID (NC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:NISSEN
Suffix:
Gender:M
Credentials:NC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 FLANNERY AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-4750
Mailing Address - Country:US
Mailing Address - Phone:646-262-1857
Mailing Address - Fax:
Practice Address - Street 1:2 FLANNERY AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-4750
Practice Address - Country:US
Practice Address - Phone:646-262-1857
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-21
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education