Provider Demographics
NPI:1922570209
Name:SMITH, NICOLE MAE (RD, CDN)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MAE
Last Name:SMITH
Suffix:
Gender:F
Credentials:RD, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:249 GLENWOOD RD
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13905-1695
Mailing Address - Country:US
Mailing Address - Phone:607-217-6513
Mailing Address - Fax:607-786-9060
Practice Address - Street 1:213 TRACY CREEK RD
Practice Address - Street 2:
Practice Address - City:VESTAL
Practice Address - State:NY
Practice Address - Zip Code:13850-1062
Practice Address - Country:US
Practice Address - Phone:607-217-6513
Practice Address - Fax:607-786-9060
Is Sole Proprietor?:No
Enumeration Date:2018-12-26
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008834133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered