Basic Information
| Provider Information | |||||||||
| NPI: | 1043719834 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICHOLSON | ||||||||
| FirstName: | VALERIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | RD, LD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BROESTL | ||||||||
| OtherFirstName: | VALERIE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | RD, LD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4200 STORY RD | ||||||||
| Address2: | |||||||||
| City: | FAIRVIEW PARK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441261750 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 25550 CHARGRIN BLVD | ||||||||
| Address2: | STE 200 | ||||||||
| City: | BEACHWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2167650500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2018 | ||||||||
| LastUpdateDate: | 02/07/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | LD.7369 | OH | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.