Provider Demographics
NPI:1629506662
Name:NICHOLS, OLIVIA ANN (RDN)
Entity Type:Individual
Prefix:MRS
First Name:OLIVIA
Middle Name:ANN
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:MS
Other - First Name:OLIVIA
Other - Middle Name:ANN
Other - Last Name:ADAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDN
Mailing Address - Street 1:826 S 14TH ST APT 208
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64501-4301
Mailing Address - Country:US
Mailing Address - Phone:308-470-1218
Mailing Address - Fax:
Practice Address - Street 1:711 MARSHALL ST
Practice Address - Street 2:
Practice Address - City:LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66048-3235
Practice Address - Country:US
Practice Address - Phone:913-684-1196
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-02
Last Update Date:2017-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2173133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered