Provider Demographics
NPI:1952187379
Name:SMITH, NICOLE ERICKA (RD, CDN)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ERICKA
Last Name:SMITH
Suffix:
Gender:F
Credentials:RD, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1227 BAY 27TH ST
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-1715
Mailing Address - Country:US
Mailing Address - Phone:516-787-7177
Mailing Address - Fax:
Practice Address - Street 1:327 BEACH 19TH ST
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-4423
Practice Address - Country:US
Practice Address - Phone:718-869-7454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-01
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
011358133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered