Provider Demographics
NPI:1710441506
Name:CUSTABLE, NICHOLETTE (RD)
Entity Type:Individual
Prefix:
First Name:NICHOLETTE
Middle Name:
Last Name:CUSTABLE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1617 DELTA ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90026-2629
Mailing Address - Country:US
Mailing Address - Phone:817-528-4387
Mailing Address - Fax:
Practice Address - Street 1:1812 VERDUGO BLVD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91208-1407
Practice Address - Country:US
Practice Address - Phone:818-790-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-25
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered