Basic Information
| Provider Information | |||||||||
| NPI: | 1750727012 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHEN | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ANDERSON | ||||||||
| OtherFirstName: | NICOLE | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | CD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1905 E. HUEBBE PARKWAY | ||||||||
| Address2: | BELOIT HEALTH SYSTEM INC | ||||||||
| City: | BELOIT | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535111842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083642200 | ||||||||
| FaxNumber: | 6083637395 | ||||||||
| Practice Location | |||||||||
| Address1: | 1905 E. HUEBBE PARKWAY | ||||||||
| Address2: | BELOIT HEALTH SYSTEM INC | ||||||||
| City: | BELOIT | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535111842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083642200 | ||||||||
| FaxNumber: | 6083637395 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2013 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 164005957 | IL | N | Dietary & Nutritional Service Providers | Dietitian, Registered | 133V00000X | 2396-29 | WI | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.