Provider Demographics
NPI:1447521653
Name:CONNOLLY, NICOLE M (RD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1287 MARS EVANS CITY RD
Mailing Address - Street 2:
Mailing Address - City:EVANS CITY
Mailing Address - State:PA
Mailing Address - Zip Code:16033-3615
Mailing Address - Country:US
Mailing Address - Phone:315-439-4824
Mailing Address - Fax:
Practice Address - Street 1:9100 BABCOCK BLVD
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15237-5815
Practice Address - Country:US
Practice Address - Phone:412-367-6468
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-19
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN003344133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered