Provider Demographics
NPI:1497057574
Name:MATSUDA, NICOLE (RD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MATSUDA
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1561 PENSACOLA ST
Mailing Address - Street 2:1405
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96822-3893
Mailing Address - Country:US
Mailing Address - Phone:808-372-4315
Mailing Address - Fax:
Practice Address - Street 1:478 LAUHALA PLACE
Practice Address - Street 2:LANAI COMMUNITY HEALTH CENTER
Practice Address - City:LANAI CITY
Practice Address - State:HI
Practice Address - Zip Code:96763
Practice Address - Country:US
Practice Address - Phone:808-565-6919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-23
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI00997848133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered