Provider Demographics
NPI:1588018907
Name:NICHOLSON, BRANDI NICOLE (RDN, IBCLC)
Entity type:Individual
Prefix:
First Name:BRANDI
Middle Name:NICOLE
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:RDN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:756 W 108TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90044-4345
Mailing Address - Country:US
Mailing Address - Phone:310-872-7426
Mailing Address - Fax:
Practice Address - Street 1:756 W 108TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90044-4345
Practice Address - Country:US
Practice Address - Phone:310-872-7426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-21
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAL-301756174N00000X
CA1012432133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No174N00000XOther Service ProvidersLactation Consultant, Non-RN