Provider Demographics
NPI:1457857682
Name:CORNELIOUS, NICOLE CARTER (RD, CSO, LD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:CARTER
Last Name:CORNELIOUS
Suffix:
Gender:F
Credentials:RD, CSO, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10245 KEMPWOOD DR STE E
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77043-1840
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10020 SPRING SHADOWS PARK CIR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77080-2208
Practice Address - Country:US
Practice Address - Phone:713-670-4683
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-05
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX960271133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered