Provider Demographics
NPI:1457895930
Name:NICKELSON, BETH ANN (RDN)
Entity Type:Individual
Prefix:MRS
First Name:BETH
Middle Name:ANN
Last Name:NICKELSON
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3930 W HANSEN RD
Mailing Address - Street 2:
Mailing Address - City:LUDINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:49431-8603
Mailing Address - Country:US
Mailing Address - Phone:231-845-6383
Mailing Address - Fax:231-845-6383
Practice Address - Street 1:3930 W HANSEN RD
Practice Address - Street 2:
Practice Address - City:LUDINGTON
Practice Address - State:MI
Practice Address - Zip Code:49431-8603
Practice Address - Country:US
Practice Address - Phone:231-845-6383
Practice Address - Fax:231-845-6383
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-19
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered