Provider Demographics
NPI:1811235195
Name:WALTERS, NICOLE (MA, RD, LDN)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:WALTERS
Suffix:
Gender:F
Credentials:MA, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 LLANDILLO RD
Mailing Address - Street 2:
Mailing Address - City:HAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19083-4708
Mailing Address - Country:US
Mailing Address - Phone:610-220-2014
Mailing Address - Fax:
Practice Address - Street 1:34 LLANDILLO RD
Practice Address - Street 2:
Practice Address - City:HAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19083-4708
Practice Address - Country:US
Practice Address - Phone:610-220-2014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-22
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN003898133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered