Provider Demographics
NPI:1659736551
Name:SELLERS-HANSEN, NICOLE ALEXANDRA (RDN)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ALEXANDRA
Last Name:SELLERS-HANSEN
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13488 MAXELLA AVE
Mailing Address - Street 2:APT 364
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-4300
Mailing Address - Country:US
Mailing Address - Phone:410-925-9648
Mailing Address - Fax:
Practice Address - Street 1:13488 MAXELLA AVE
Practice Address - Street 2:APT 364
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-4300
Practice Address - Country:US
Practice Address - Phone:410-925-9648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-18
Last Update Date:2015-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86054096133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered