Provider Demographics
NPI:1447975503
Name:FEDERICA, NICOLE (MS, RD, LDN)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:FEDERICA
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1211 RIDGE TRACE DRIVE
Mailing Address - Street 2:APT. 102, BUILDING 16
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27606
Mailing Address - Country:US
Mailing Address - Phone:973-487-6286
Mailing Address - Fax:
Practice Address - Street 1:23 SUNNYBROOK RD STE 316
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-1874
Practice Address - Country:US
Practice Address - Phone:919-350-6002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-11
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL007081133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered