Provider Demographics
NPI:1437776267
Name:PREDER, NICOLE MCKENZIE (RDN)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MCKENZIE
Last Name:PREDER
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2374 FREEDOM BLVD APT A2
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29505-6175
Mailing Address - Country:US
Mailing Address - Phone:920-207-7168
Mailing Address - Fax:
Practice Address - Street 1:555 E CHEVES ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506-2617
Practice Address - Country:US
Practice Address - Phone:920-207-7168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-27
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
86091928OtherCOMMISSION ON DIETETIC REGISTRATION