Provider Demographics
NPI:1962155663
Name:HAHN, NICOLE LEE-ANN
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:LEE-ANN
Last Name:HAHN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:LEE-ANN
Other - Last Name:PRIMAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, RDN, CNSC
Mailing Address - Street 1:4177 N 181ST LN
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-5209
Mailing Address - Country:US
Mailing Address - Phone:623-570-4086
Mailing Address - Fax:
Practice Address - Street 1:4177 N 181ST LN
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-5209
Practice Address - Country:US
Practice Address - Phone:623-570-4086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-02
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
963756133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered