Provider Demographics
NPI:1245325554
Name:NICKLESS, KATHERINE S (RD LD)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:S
Last Name:NICKLESS
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 1:157 CLINIC #203
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117
Mailing Address - Country:US
Mailing Address - Phone:770-832-0429
Mailing Address - Fax:770-838-9108
Practice Address - Street 1:157 CLINIC #203
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117
Practice Address - Country:US
Practice Address - Phone:770-832-0429
Practice Address - Fax:770-838-9108
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD002692133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered