Provider Demographics
NPI:1962593665
Name:DOUGHTY, NICOLE THERIAULT (RD, LD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:THERIAULT
Last Name:DOUGHTY
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 ROOSEVELT AVE
Mailing Address - Street 2:PO BOX 948
Mailing Address - City:FORT FAIRFIELD
Mailing Address - State:ME
Mailing Address - Zip Code:04742-1126
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:140 ACADEMY ST
Practice Address - Street 2:
Practice Address - City:PRESQUE ISLE
Practice Address - State:ME
Practice Address - Zip Code:04769-3102
Practice Address - Country:US
Practice Address - Phone:207-768-4358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MED1710133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMT0954Medicare ID - Type Unspecified