Provider Demographics
NPI:1891386371
Name:NOURISHED LIFE NUTRITION, PLLC
Entity Type:Organization
Organization Name:NOURISHED LIFE NUTRITION, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:BROOKE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRISCOE
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RD, CDN
Authorized Official - Phone:315-528-4711
Mailing Address - Street 1:4801 JOYCE PL
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13090-6911
Mailing Address - Country:US
Mailing Address - Phone:315-528-4711
Mailing Address - Fax:
Practice Address - Street 1:4801 JOYCE PL
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13090-6911
Practice Address - Country:US
Practice Address - Phone:315-528-4711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-28
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty