Provider Demographics
NPI:1457070708
Name:SMITH, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 EDGEMORE RD
Mailing Address - Street 2:
Mailing Address - City:SECANE
Mailing Address - State:PA
Mailing Address - Zip Code:19018-2718
Mailing Address - Country:US
Mailing Address - Phone:610-675-8225
Mailing Address - Fax:
Practice Address - Street 1:1991 SPROUL RD STE 200
Practice Address - Street 2:
Practice Address - City:BROOMALL
Practice Address - State:PA
Practice Address - Zip Code:19008-3518
Practice Address - Country:US
Practice Address - Phone:484-476-6230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-22
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA007844133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered