Provider Demographics
NPI:1306714548
Name:GOLLY, NICOLE E
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:E
Last Name:GOLLY
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 1:76 PINE VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:HIGH ROLLS MOUNTAIN PARK
Mailing Address - State:NM
Mailing Address - Zip Code:88325-9068
Mailing Address - Country:US
Mailing Address - Phone:928-421-1246
Mailing Address - Fax:
Practice Address - Street 1:76 PINE VALLEY DR
Practice Address - Street 2:
Practice Address - City:HIGH ROLLS MOUNTAIN PARK
Practice Address - State:NM
Practice Address - Zip Code:88325-9068
Practice Address - Country:US
Practice Address - Phone:928-421-1246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-28
Last Update Date:2025-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education