Provider Demographics
NPI:1750655007
Name:KIZITAFF, NICOLE LYNNE (RDN)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYNNE
Last Name:KIZITAFF
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 1:126 DAVIS AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT EPHRAIM
Mailing Address - State:NJ
Mailing Address - Zip Code:08059-1614
Mailing Address - Country:US
Mailing Address - Phone:856-655-8182
Mailing Address - Fax:
Practice Address - Street 1:126 DAVIS AVE
Practice Address - Street 2:
Practice Address - City:MOUNT EPHRAIM
Practice Address - State:NJ
Practice Address - Zip Code:08059-1614
Practice Address - Country:US
Practice Address - Phone:856-655-8182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-05
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1019387133V00000X
NJ1019387133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered