Provider Demographics
NPI:1396632865
Name:MACKEY, NICOLE (MS, RD, CSSD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MACKEY
Suffix:
Gender:F
Credentials:MS, RD, CSSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3639 HAVEN AVE UNIT C114
Mailing Address - Street 2:
Mailing Address - City:MENLO PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94025-1586
Mailing Address - Country:US
Mailing Address - Phone:607-434-8520
Mailing Address - Fax:
Practice Address - Street 1:300 PASTEUR DR # H1207
Practice Address - Street 2:
Practice Address - City:STANFORD
Practice Address - State:CA
Practice Address - Zip Code:94305-2200
Practice Address - Country:US
Practice Address - Phone:650-285-9164
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-18
Last Update Date:2025-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1501XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Sports Dietetics