Provider Demographics
NPI:1962826560
Name:LARSON, NIKOLE (RD)
Entity Type:Individual
Prefix:MRS
First Name:NIKOLE
Middle Name:
Last Name:LARSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4536 LOGANS WAY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-9141
Mailing Address - Country:US
Mailing Address - Phone:706-825-4944
Mailing Address - Fax:
Practice Address - Street 1:1719 MAGNOLIA WAY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-9482
Practice Address - Country:US
Practice Address - Phone:706-825-4944
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-18
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD002687133VN1005X
SC825133VN1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal