MEDICARE: NICOLE MASON NUTRITION, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian

General Provider Information

NPI Number	:	1235994906
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NICOLE MASON NUTRITION, LLC

Provider Business Mailing Address
First Line	:	3505 ELLICOTT MILLS DR STE A1
Second Line	:
City	:	ELLICOTT CITY
State	:	MD
Zip	:	21043-4599
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7610A COACHLIGHT LN
Second Line	:
City	:	ELLICOTT CITY
State	:	MD
Zip	:	21043-8029
Country	:	US
Telephone Number	:	443-267-4270
Fax Number	:

Authorized Official
Title or Position	:	REGISTERED DIETITIAN
Name	:	NICOLE MASON
Credential	:	MS, RD, LDN
Telephone Number	:	443-267-4270

Provider Enumeration Date	:	02/20/2024
Last Update Date	:	02/20/2024

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