Provider Demographics
NPI:1922774751
Name:NICKOLAUS, THERESA RENEE (RD, LD, IBCLC)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:RENEE
Last Name:NICKOLAUS
Suffix:
Gender:F
Credentials:RD, LD, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 SCENIC OAKS CT
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:MO
Mailing Address - Zip Code:63052-3457
Mailing Address - Country:US
Mailing Address - Phone:314-363-6186
Mailing Address - Fax:
Practice Address - Street 1:1011 SCENIC OAKS CT
Practice Address - Street 2:
Practice Address - City:IMPERIAL
Practice Address - State:MO
Practice Address - Zip Code:63052-3457
Practice Address - Country:US
Practice Address - Phone:314-363-6186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-20
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
L-124884174N00000X
MO2011041352133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No174N00000XOther Service ProvidersLactation Consultant, Non-RN