Provider Demographics
NPI:1710640503
Name:SIMONE NUTRITION
Entity Type:Organization
Organization Name:SIMONE NUTRITION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, REGISTERED DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMONE
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RDN
Authorized Official - Phone:617-775-1255
Mailing Address - Street 1:163 HIGHLAND AVE # 1042
Mailing Address - Street 2:
Mailing Address - City:NEEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02494-3025
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:163 HIGHLAND AVE # 1042
Practice Address - Street 2:
Practice Address - City:NEEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02494-3025
Practice Address - Country:US
Practice Address - Phone:617-775-1255
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-19
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3655OtherLICENSE NUMBER