Healthcare Provider Details

I. General information

NPI: 1962826560
Provider Name (Legal Business Name): NIKOLE LARSON RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2014
Last Update Date: 02/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1719 MAGNOLIA WAY
AUGUSTA GA
30909-9482
US

IV. Provider business mailing address

4536 LOGANS WAY
AUGUSTA GA
30909-9141
US

V. Phone/Fax

Practice location:
  • Phone: 706-825-4944
  • Fax:
Mailing address:
  • Phone: 706-825-4944
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License NumberLD002687
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number825
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: