Provider Demographics
NPI:1023417110
Name:BRAY, NICKI NICOLE (RD)
Entity type:Individual
Prefix:
First Name:NICKI
Middle Name:NICOLE
Last Name:BRAY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:NICKI
Other - Middle Name:NICOLE
Other - Last Name:MAYS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:955 BRAY RD
Mailing Address - Street 2:
Mailing Address - City:BEECH BLUFF
Mailing Address - State:TN
Mailing Address - Zip Code:38313-1845
Mailing Address - Country:US
Mailing Address - Phone:731-608-3403
Mailing Address - Fax:
Practice Address - Street 1:955 BRAY RD
Practice Address - Street 2:
Practice Address - City:BEECH BLUFF
Practice Address - State:TN
Practice Address - Zip Code:38313-1845
Practice Address - Country:US
Practice Address - Phone:731-608-3403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-14
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2635133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered