Provider Demographics
NPI:1366622904
Name:MEADOW, NICOLE DANA (MPN, RD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:DANA
Last Name:MEADOW
Suffix:
Gender:F
Credentials:MPN, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5400 BALBOA BLVD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-1502
Mailing Address - Country:US
Mailing Address - Phone:818-304-1876
Mailing Address - Fax:
Practice Address - Street 1:5400 BALBOA BLVD
Practice Address - Street 2:SUITE 301
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-1502
Practice Address - Country:US
Practice Address - Phone:818-304-1876
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-12
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA915960133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered