MEDICARE: NICOLE CARTER CORNELIOUS RD, CSO, LD

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	960271	TX

General Provider Information

NPI Number	:	1457857682
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE CARTER CORNELIOUS RD, CSO, LD

Provider Business Mailing Address
First Line	:	10245 KEMPWOOD DR STE E
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77043-1840
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	10020 SPRING SHADOWS PARK CIR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77080-2208
Country	:	US
Telephone Number	:	713-670-4683
Fax Number	:

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

Provider Enumeration Date	:	04/05/2018
Last Update Date	:	04/05/2018

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