Provider Demographics
NPI:1326279431
Name:CHASE, NICOLE ANN (RD)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:ANN
Last Name:CHASE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6824 JEWELL AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76112-5636
Mailing Address - Country:US
Mailing Address - Phone:817-789-8404
Mailing Address - Fax:
Practice Address - Street 1:6824 JEWELL AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76112-5636
Practice Address - Country:US
Practice Address - Phone:817-789-8404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-06
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT81015133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered