Provider Demographics
NPI:1558048967
Name:PERRY, NICKLAUS BLAKE (CNC, CPT, CES)
Entity Type:Individual
Prefix:
First Name:NICKLAUS
Middle Name:BLAKE
Last Name:PERRY
Suffix:
Gender:M
Credentials:CNC, CPT, CES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1019 ELKGROVE AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-6113
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1019 ELKGROVE AVE APT 3
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291-6113
Practice Address - Country:US
Practice Address - Phone:818-826-3090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-28
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education