Provider Demographics
NPI:1023319365
Name:PUTNAM, NICOLLE JEANETTE (RD)
Entity type:Individual
Prefix:
First Name:NICOLLE
Middle Name:JEANETTE
Last Name:PUTNAM
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 1:321 E 7TH ST
Mailing Address - Street 2:#208
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52803-5513
Mailing Address - Country:US
Mailing Address - Phone:515-720-9178
Mailing Address - Fax:
Practice Address - Street 1:2001 5TH ST
Practice Address - Street 2:SUITE 51
Practice Address - City:SILVIS
Practice Address - State:IL
Practice Address - Zip Code:61282-2903
Practice Address - Country:US
Practice Address - Phone:309-792-1507
Practice Address - Fax:309-792-1518
Is Sole Proprietor?:No
Enumeration Date:2010-11-03
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.005326133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered