Provider Demographics
NPI:1194919746
Name:NICHOLS, LYNN W (RD LDN)
Entity type:Individual
Prefix:
First Name:LYNN
Middle Name:W
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:RD LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 821807
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-1807
Mailing Address - Country:US
Mailing Address - Phone:610-891-3490
Mailing Address - Fax:610-891-3493
Practice Address - Street 1:1068 W BALTIMORE PIKE
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-5104
Practice Address - Country:US
Practice Address - Phone:610-891-3490
Practice Address - Fax:610-891-3493
Is Sole Proprietor?:No
Enumeration Date:2007-08-28
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN001640133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA083387JN7Medicare UPIN