Provider Demographics
NPI:1104230192
Name:WHITE, NICOLE KATHERINE (RD, CSSD, LDN)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:KATHERINE
Last Name:WHITE
Suffix:
Gender:F
Credentials:RD, CSSD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2004 98 PALMS BLVD UNIT 4312
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-2778
Mailing Address - Country:US
Mailing Address - Phone:901-485-4939
Mailing Address - Fax:
Practice Address - Street 1:100 SERVAIS WAY
Practice Address - Street 2:RM 210
Practice Address - City:HURLBURT FIELD
Practice Address - State:FL
Practice Address - Zip Code:32544
Practice Address - Country:US
Practice Address - Phone:850-884-4661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-17
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164006212133V00000X
IA084432133VN1501X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1501XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Sports Dietetics
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered