Provider Demographics
NPI:1881210987
Name:ELLIOTT, NICOLE R
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:R
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 JOE KNOX AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-9203
Mailing Address - Country:US
Mailing Address - Phone:919-417-6625
Mailing Address - Fax:
Practice Address - Street 1:132 JOE KNOX AVE
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-9202
Practice Address - Country:US
Practice Address - Phone:919-417-6625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-24
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL004453133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered