Provider Demographics
NPI:1417928821
Name:PACE, NICOLETTE M (MS,RD, CDE,CDN, CFCS)
Entity Type:Individual
Prefix:PROF
First Name:NICOLETTE
Middle Name:M
Last Name:PACE
Suffix:
Gender:F
Credentials:MS,RD, CDE,CDN, CFCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:295 NORTHERN BLVD
Mailing Address - Street 2:STE 105
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-4706
Mailing Address - Country:US
Mailing Address - Phone:516-482-3100
Mailing Address - Fax:516-482-3131
Practice Address - Street 1:295 NORTHERN BLVD
Practice Address - Street 2:STE 105
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-4706
Practice Address - Country:US
Practice Address - Phone:516-482-3100
Practice Address - Fax:516-482-3131
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005258-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
06416Medicare UPIN