Healthcare Provider Details

I. General information

NPI: 1063396786
Provider Name (Legal Business Name): NICOLE BARTELS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2025
Last Update Date: 08/05/2025
Certification Date: 08/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 BUTLER AVE
MARTINSBURG WV
25405-9990
US

IV. Provider business mailing address

5404 MERSEA CT
BURKE VA
22015-1929
US

V. Phone/Fax

Practice location:
  • Phone: 800-817-3807
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86374325
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: