Provider Demographics
NPI:1013498328
Name:WILLIAMS, NICOLE LEE (RD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LEE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:LEE
Other - Last Name:EHRHART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:155 CALLE PORTAL STE 100
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-2900
Mailing Address - Country:US
Mailing Address - Phone:520-515-8673
Mailing Address - Fax:520-515-8663
Practice Address - Street 1:155 CALLE PORTAL STE 300
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-2900
Practice Address - Country:US
Practice Address - Phone:520-459-3011
Practice Address - Fax:520-458-4467
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-24
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ871698133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered