Provider Demographics
NPI:1063712396
Name:DEAN, NICOLE (RD,LDN,CNSC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:DEAN
Suffix:
Gender:F
Credentials:RD,LDN,CNSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8151 RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-2902
Mailing Address - Country:US
Mailing Address - Phone:215-487-2500
Mailing Address - Fax:
Practice Address - Street 1:8151 RIDGE AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128-2902
Practice Address - Country:US
Practice Address - Phone:215-487-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-03
Last Update Date:2011-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN002287133V00000X
PA867433133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered