Provider Demographics
NPI:1790257558
Name:NICOLAS, DIANA M (RD, CDE)
Entity Type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:M
Last Name:NICOLAS
Suffix:
Gender:F
Credentials:RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4252 TRINITY PL NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107
Mailing Address - Country:US
Mailing Address - Phone:505-850-8430
Mailing Address - Fax:
Practice Address - Street 1:8300 CONSTITUTION AVE NE BLD D
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110
Practice Address - Country:US
Practice Address - Phone:505-559-6404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-18
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMLD-1263133V00000X, 133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered