Provider Demographics
NPI:1932486024
Name:SUPER, NICHOLLE KAREN (RD, CD)
Entity Type:Individual
Prefix:
First Name:NICHOLLE
Middle Name:KAREN
Last Name:SUPER
Suffix:
Gender:F
Credentials:RD, CD
Other - Prefix:
Other - First Name:NICHOLLE
Other - Middle Name:KAREN
Other - Last Name:BIRDSILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, CD
Mailing Address - Street 1:200 1ST ST SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55905-0001
Mailing Address - Country:US
Mailing Address - Phone:715-838-5222
Mailing Address - Fax:
Practice Address - Street 1:2321 STOUT RD
Practice Address - Street 2:
Practice Address - City:MENOMONIE
Practice Address - State:WI
Practice Address - Zip Code:54751-7003
Practice Address - Country:US
Practice Address - Phone:715-235-5531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-03
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2412-29133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered