Healthcare Provider Details

I. General information

NPI: 1396706404
Provider Name (Legal Business Name): JULIE GAREY RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JULIE K NICHOLLS

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 10/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 S STATE ST
DOVER DE
19901-3530
US

IV. Provider business mailing address

328 E BROADSTAIRS PL APT D104
DOVER DE
19904-9775
US

V. Phone/Fax

Practice location:
  • Phone: 302-744-6842
  • Fax:
Mailing address:
  • Phone: 302-674-8579
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDN-0000210
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: