Provider Demographics
NPI:1184888059
Name:LAVERTY, NICOLE LEIGH (RD, LDN)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:LEIGH
Last Name:LAVERTY
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 30181
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103-8181
Mailing Address - Country:US
Mailing Address - Phone:215-496-2662
Mailing Address - Fax:
Practice Address - Street 1:12 S 23RD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19103-3014
Practice Address - Country:US
Practice Address - Phone:215-496-2662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-10
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN003704133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered