MEDICARE: MRS. JUDITH A NICHOLLS MBA

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

General Provider Information

NPI Number	:	1790017408
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JUDITH A NICHOLLS MBA

Provider Business Mailing Address
First Line	:	PO BOX 1305
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29578-1305
Country	:	US
Telephone Number	:	843-448-4222
Fax Number	:

Provider Business Practice Location Address
First Line	:	507 ROBERT M GRISSOM PKWY
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29577-6576
Country	:	US
Telephone Number	:	843-448-4222
Fax Number	:

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

Provider Enumeration Date	:	02/04/2010
Last Update Date	:	04/21/2010

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