Provider Demographics
NPI:1649491168
Name:NICHTER, LISA COLLETE (LD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:COLLETE
Last Name:NICHTER
Suffix:
Gender:F
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 CAIRO RD
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-4255
Mailing Address - Country:US
Mailing Address - Phone:229-228-8800
Mailing Address - Fax:
Practice Address - Street 1:915 GORDON AVE
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-6614
Practice Address - Country:US
Practice Address - Phone:229-228-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002153133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA71BBBDXMedicare PIN