Provider Demographics
NPI:1952657785
Name:GILLES, NICOLE (RD, CDE, CSR)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:GILLES
Suffix:
Gender:F
Credentials:RD, CDE, CSR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12523 LIMONITE AVE # 440-163
Mailing Address - Street 2:
Mailing Address - City:MIRA LOMA
Mailing Address - State:CA
Mailing Address - Zip Code:91752-3665
Mailing Address - Country:US
Mailing Address - Phone:951-444-5588
Mailing Address - Fax:877-991-8768
Practice Address - Street 1:12523 LIMONITE AVE
Practice Address - Street 2:#440-163
Practice Address - City:MIRA LOMA
Practice Address - State:CA
Practice Address - Zip Code:91752-3665
Practice Address - Country:US
Practice Address - Phone:951-444-5588
Practice Address - Fax:877-991-8768
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-30
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1034797133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered