Healthcare Provider Details

I. General information

NPI: 1548566268
Provider Name (Legal Business Name): NICOLE MARIE HAMILTON NTP, LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2011
Last Update Date: 01/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1375 LUDWIG AVE
SANTA ROSA CA
95407-7356
US

IV. Provider business mailing address

1375 LUDWIG AVE
SANTA ROSA CA
95407-7356
US

V. Phone/Fax

Practice location:
  • Phone: 707-227-8230
  • Fax:
Mailing address:
  • Phone: 707-227-8230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number000390
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: