Provider Demographics
NPI:1548680283
Name:BENNER, NICOLE I (RD, LDN)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:I
Last Name:BENNER
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5238 STRATHMORE DR
Mailing Address - Street 2:
Mailing Address - City:MECHANICSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17050-6816
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:123 FORSTER ST
Practice Address - Street 2:ASSOCIATION OFFICE, HARRISBURG AREA YMCA
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17102-3409
Practice Address - Country:US
Practice Address - Phone:717-515-4402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-21
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN001026133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered