Provider Demographics
NPI:1376355792
Name:ROACH, NICOLE (RD CDN CDCES)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:ROACH
Suffix:
Gender:F
Credentials:RD CDN CDCES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 HUDSON ST
Mailing Address - Street 2:
Mailing Address - City:HOBOKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07030-5249
Mailing Address - Country:US
Mailing Address - Phone:516-508-2299
Mailing Address - Fax:
Practice Address - Street 1:1000 HUDSON ST
Practice Address - Street 2:
Practice Address - City:HOBOKEN
Practice Address - State:NJ
Practice Address - Zip Code:07030-5249
Practice Address - Country:US
Practice Address - Phone:516-508-2299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-22
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY86046060133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered