Healthcare Provider Details

I. General information

NPI: 1306714548
Provider Name (Legal Business Name): NICOLE E GOLLY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2025
Last Update Date: 10/28/2025
Certification Date: 10/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

76 PINE VALLEY DR
HIGH ROLLS MOUNTAIN PARK NM
88325-9068
US

IV. Provider business mailing address

76 PINE VALLEY DR
HIGH ROLLS MOUNTAIN PARK NM
88325-9068
US

V. Phone/Fax

Practice location:
  • Phone: 928-421-1246
  • Fax:
Mailing address:
  • Phone: 928-421-1246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: