Provider Demographics
NPI:1720636145
Name:MERRYMAN, NICOLE (RD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MERRYMAN
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:PO BOX 320044
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22320-4044
Mailing Address - Country:US
Mailing Address - Phone:707-583-1277
Mailing Address - Fax:
Practice Address - Street 1:2455 MANDEVILLE LN
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-6124
Practice Address - Country:US
Practice Address - Phone:707-583-1277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-28
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86090490133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered