Healthcare Provider Details

I. General information

NPI: 1053980763
Provider Name (Legal Business Name): NOURISHED ONE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2021
Last Update Date: 06/18/2021
Certification Date: 06/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6161 NW 2ND AVE APT 214
BOCA RATON FL
33487-3047
US

IV. Provider business mailing address

6161 NW 2ND AVE APT 214
BOCA RATON FL
33487-3047
US

V. Phone/Fax

Practice location:
  • Phone: 817-542-6323
  • Fax:
Mailing address:
  • Phone: 817-542-6323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State

VIII. Authorized Official

Name: ANNIE LIN
Title or Position: OWNER
Credential: CNS
Phone: 817-542-6323