Provider Demographics
NPI:1679812663
Name:NICKERSON, MOREEN N (MS, RD)
Entity Type:Individual
Prefix:
First Name:MOREEN
Middle Name:N
Last Name:NICKERSON
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:574 MAIN ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:EAST AURORA
Mailing Address - State:NY
Mailing Address - Zip Code:14052-1751
Mailing Address - Country:US
Mailing Address - Phone:716-608-3110
Mailing Address - Fax:
Practice Address - Street 1:574 MAIN ST
Practice Address - Street 2:SUITE 203
Practice Address - City:EAST AURORA
Practice Address - State:NY
Practice Address - Zip Code:14052-1751
Practice Address - Country:US
Practice Address - Phone:716-608-3110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-11
Last Update Date:2013-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY86001885133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered