Provider Demographics
NPI:1245563741
Name:NICASIO, VELA A (RD, CDE)
Entity Type:Individual
Prefix:MRS
First Name:VELA
Middle Name:A
Last Name:NICASIO
Suffix:
Gender:F
Credentials:RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1049 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01103
Mailing Address - Country:US
Mailing Address - Phone:413-739-1100
Mailing Address - Fax:413-735-1133
Practice Address - Street 1:1049 MAIN STREET
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01103
Practice Address - Country:US
Practice Address - Phone:413-739-1100
Practice Address - Fax:413-735-1133
Is Sole Proprietor?:No
Enumeration Date:2009-09-15
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2867133V00000X
CT852121133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2867OtherLICENSE
MA110028120Medicaid
CT852121OtherCOMMISSION ON DIETETIC REGISTRATION
MA110028120Medicaid
CT852121OtherCOMMISSION ON DIETETIC REGISTRATION
MAM21172 (GROUP)Medicare UPIN