MEDICARE: NICOLE STREALY RDN, LD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	LDD000446	OR

General Provider Information

NPI Number	:	1558806463
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE STREALY RDN, LD

Provider Business Mailing Address
First Line	:	PO BOX 2013
Second Line	:
City	:	LAKE OSWEGO
State	:	OR
Zip	:	97035-0606
Country	:	US
Telephone Number	:	503-974-6454
Fax Number	:	888-529-7679

Provider Business Practice Location Address
First Line	:	5021 TUALATA LN
Second Line	:
City	:	LAKE OSWEGO
State	:	OR
Zip	:	97035-7116
Country	:	US
Telephone Number	:	503-974-6454
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/01/2017
Last Update Date	:	01/01/2017

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