Provider Demographics
NPI:1326326380
Name:NICOL, MELISSA A (DIETICIAN)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:A
Last Name:NICOL
Suffix:
Gender:F
Credentials:DIETICIAN
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:A
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DIETICIAN
Mailing Address - Street 1:PO BOX 19640
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9640
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:217-545-9217
Practice Address - Street 1:415 N 9TH ST
Practice Address - Street 2:STE 6W100
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-5303
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:217-545-9217
Is Sole Proprietor?:No
Enumeration Date:2011-07-25
Last Update Date:2013-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164005484133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL164.005484OtherSTATE OF ILLINOIS LICENSE
IL164.005484OtherSTATE OF ILLINOIS LICENSE