Provider Demographics
NPI:1134795578
Name:DUBE, NICOLE (MS, CDN, CNS)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:DUBE
Suffix:
Gender:F
Credentials:MS, CDN, CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1022 BOULEVARD # 235
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06119-1801
Mailing Address - Country:US
Mailing Address - Phone:413-374-9920
Mailing Address - Fax:
Practice Address - Street 1:484 GLEN ST
Practice Address - Street 2:
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06051-3409
Practice Address - Country:US
Practice Address - Phone:413-374-9920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-27
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT03887573133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist