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General NPI Number Information
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NPI Number | 1104230192
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Entity Type | Individual
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Provider Name | NICOLE KATHERINE WHITE RD, CSSD, LDN
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Gender | Female
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Dates
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Enumeration Date | 06/17/2014
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Last Update Date | 06/10/2022
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Provider Practice Location Address
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Address Line | 100 SERVAIS WAY RM 210
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City | HURLBURT FIELD
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State | FL
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Zip | 32544
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Country | US
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Telephone | 850-884-4661
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Fax |
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Provider Business Mailing Address
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Address Line | 2004 98 PALMS BLVD UNIT 4312
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City | DESTIN
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State | FL
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Zip | 32541-2778
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Country | US
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Telephone | 901-485-4939
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number | 164006212
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 133VN1501X
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Taxonomy Name | Sports Dietetics Nutrition Registered Dietitian
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License Number | 084432
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License Number State | IA
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