Provider Demographics
NPI:1891309878
Name:NICHOLSON, STEPHANIE (MS, RDN, LDN)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:MS, RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2708 W PRICE AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33611-3834
Mailing Address - Country:US
Mailing Address - Phone:813-712-0981
Mailing Address - Fax:
Practice Address - Street 1:2708 W PRICE AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33611-3834
Practice Address - Country:US
Practice Address - Phone:813-712-0981
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-07
Last Update Date:2020-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL01020954133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered