Provider Demographics
NPI:1386917169
Name:NICHOLS, LILY ANNA (RD)
Entity type:Individual
Prefix:MRS
First Name:LILY
Middle Name:ANNA
Last Name:NICHOLS
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 1:945 8TH ST
Mailing Address - Street 2:
Mailing Address - City:HERMOSA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90254-4310
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21840 NORMANDIE AVE
Practice Address - Street 2:SUITE 1000
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90502-2047
Practice Address - Country:US
Practice Address - Phone:310-328-5699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-09
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
01018649133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered