Healthcare Provider Details

I. General information

NPI: 1679559710
Provider Name (Legal Business Name): ASHLEY JO NICHOLSON RD,LD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/20/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 JARRETT WHITE RD TRIPLER ARMY MEDICAL CENTER ATTN:MCHK-QS
TRIPLER AMC HI
96859-5001
US

IV. Provider business mailing address

1 JARRETT WHITE RD TRIPLER ARMY MEDICAL CENTER ATTN:MCHK-QS
TRIPLER AMC HI
96859-5001
US

V. Phone/Fax

Practice location:
  • Phone: 808-433-2460
  • Fax: 808-433-1558
Mailing address:
  • Phone: 808-433-2460
  • Fax: 808-433-1558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1215
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: