Healthcare Provider Details

I. General information

NPI: 1538099494
Provider Name (Legal Business Name): NATALIE NICHOLAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2026
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 FIELDSTONE LN
ITHACA NY
14850-9596
US

IV. Provider business mailing address

100 FIELDSTONE LN
ITHACA NY
14850-9596
US

V. Phone/Fax

Practice location:
  • Phone: 607-391-5387
  • Fax:
Mailing address:
  • Phone: 607-391-5387
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number009059-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: