MEDICARE: TABITHA NICHOLAS M.S., RD, LDN

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	133NN1002X	Nutrition Education Nutritionist	2038	LA
2	133VN1005X	Renal Nutrition Registered Dietitian	2038	LA
3	133V00000X	Registered Dietitian	2038	LA

General Provider Information

NPI Number	:	1407175888
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TABITHA NICHOLAS M.S., RD, LDN

Provider Business Mailing Address
First Line	:	3201 FLATWOOD DR
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70607-4324
Country	:	US
Telephone Number	:	337-419-0942
Fax Number	:	337-314-1243

Provider Business Practice Location Address
First Line	:	114 STATE ST
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70605-5718
Country	:	US
Telephone Number	:	337-419-0942
Fax Number	:	337-314-1243

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/24/2010
Last Update Date	:	11/11/2021

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