Basic Information
| Provider Information | |||||||||
| NPI: | 1245563741 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICASIO | ||||||||
| FirstName: | VELA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RD, CDE | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1049 MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137391100 | ||||||||
| FaxNumber: | 4137351133 | ||||||||
| Practice Location | |||||||||
| Address1: | 1049 MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137391100 | ||||||||
| FaxNumber: | 4137351133 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2009 | ||||||||
| LastUpdateDate: | 05/12/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 2867 | MA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered | 133V00000X | 852121 | CT | N | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 2867 | 01 | MA | LICENSE | OTHER | 110028120 | 05 | MA | MEDICAID | 852121 | 01 | CT | COMMISSION ON DIETETIC REGISTRATION | OTHER |