Provider Demographics
NPI:1558806463
Name:STREALY, NICOLE (RDN, LD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:STREALY
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2013
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-0606
Mailing Address - Country:US
Mailing Address - Phone:503-974-6454
Mailing Address - Fax:888-529-7679
Practice Address - Street 1:5021 TUALATA LN
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-7116
Practice Address - Country:US
Practice Address - Phone:503-974-6454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-01
Last Update Date:2017-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLDD000446133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered