Provider Demographics
NPI:1407175888
Name:NICHOLAS, TABITHA (MS, RD, LDN)
Entity Type:Individual
Prefix:
First Name:TABITHA
Middle Name:
Last Name:NICHOLAS
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3201 FLATWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70607-4324
Mailing Address - Country:US
Mailing Address - Phone:337-419-0942
Mailing Address - Fax:337-314-1243
Practice Address - Street 1:114 STATE ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-5718
Practice Address - Country:US
Practice Address - Phone:337-419-0942
Practice Address - Fax:337-314-1243
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-24
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2038133NN1002X, 133VN1005X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal