Provider Demographics
NPI:1275191801
Name:GERDES, NIKELLE (MS, RD, LMNT, CNSC)
Entity Type:Individual
Prefix:
First Name:NIKELLE
Middle Name:
Last Name:GERDES
Suffix:
Gender:F
Credentials:MS, RD, LMNT, CNSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:433 E 6TH ST
Mailing Address - Street 2:
Mailing Address - City:MINDEN
Mailing Address - State:NE
Mailing Address - Zip Code:68959-1311
Mailing Address - Country:US
Mailing Address - Phone:817-675-0034
Mailing Address - Fax:
Practice Address - Street 1:433 E 6TH ST
Practice Address - Street 2:
Practice Address - City:MINDEN
Practice Address - State:NE
Practice Address - Zip Code:68959-1311
Practice Address - Country:US
Practice Address - Phone:817-675-0034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-29
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1012690133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered