Provider Demographics
NPI:1508473885
Name:BODIN, NICOLE H (RD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:H
Last Name:BODIN
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 1:215 1ST ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02142-1213
Mailing Address - Country:US
Mailing Address - Phone:617-491-8989
Mailing Address - Fax:
Practice Address - Street 1:215 1ST ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02142-1213
Practice Address - Country:US
Practice Address - Phone:617-491-8989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-30
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5193133V00000X
133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered