Provider Demographics
NPI:1063287498
Name:COPENHAVER, NICHOLAS
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:COPENHAVER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 ROUND HILL RD
Mailing Address - Street 2:
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473-4366
Mailing Address - Country:US
Mailing Address - Phone:203-824-0463
Mailing Address - Fax:
Practice Address - Street 1:4 RESEARCH PKWY
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-1929
Practice Address - Country:US
Practice Address - Phone:860-351-3144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-15
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT86302653133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered