Provider Demographics
NPI:1790017408
Name:NICHOLLS, JUDITH A (MBA)
Entity Type:Individual
Prefix:MRS
First Name:JUDITH
Middle Name:A
Last Name:NICHOLLS
Suffix:
Gender:F
Credentials:MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1305
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29578-1305
Mailing Address - Country:US
Mailing Address - Phone:843-448-4222
Mailing Address - Fax:
Practice Address - Street 1:507 ROBERT M GRISSOM PKWY
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-6576
Practice Address - Country:US
Practice Address - Phone:843-448-4222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-04
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education