Provider Demographics
NPI:1790923183
Name:ISHAM, NICOLE M (RD, CD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:ISHAM
Suffix:
Gender:F
Credentials:RD, CD
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:M
Other - Last Name:ARMSTRONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, CD
Mailing Address - Street 1:2845 GREENBRIER RD
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2845 GREENBRIER RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311
Practice Address - Country:US
Practice Address - Phone:920-288-3213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-23
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2140-29133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered