Provider Demographics
NPI:1598270308
Name:THELEN, NICOLE THERESE (MS, RD, LD, CNSC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:THERESE
Last Name:THELEN
Suffix:
Gender:F
Credentials:MS, RD, LD, CNSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4525 CAMERON VALLEY PKWY STE 4100
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-4378
Mailing Address - Country:US
Mailing Address - Phone:704-302-9462
Mailing Address - Fax:704-302-9402
Practice Address - Street 1:4525 CAMERON VALLEY PKWY STE 4100
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-4378
Practice Address - Country:US
Practice Address - Phone:704-302-9462
Practice Address - Fax:704-302-9402
Is Sole Proprietor?:No
Enumeration Date:2017-12-04
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133V00000X
NCL005475133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
86017776OtherCOMMISSION ON DIETETIC REGISTRATION