Provider Demographics
NPI:1952514952
Name:NICHOLSON, GAYLA (RD)
Entity Type:Individual
Prefix:
First Name:GAYLA
Middle Name:
Last Name:NICHOLSON
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 947
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:MT
Mailing Address - Zip Code:59047-0947
Mailing Address - Country:US
Mailing Address - Phone:406-220-3268
Mailing Address - Fax:
Practice Address - Street 1:320 N MAIN ST STE 3
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:MT
Practice Address - Zip Code:59047-2000
Practice Address - Country:US
Practice Address - Phone:406-220-3268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT318133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0280514Medicaid