Provider Demographics
NPI:1245048784
Name:O'BRIEN, NICOLE GRACE (RD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:GRACE
Last Name:O'BRIEN
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 1:640 W 170TH ST APT 3A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-3532
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:640 W 170TH ST APT 3A
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3532
Practice Address - Country:US
Practice Address - Phone:201-410-3233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-30
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty