Provider Demographics
NPI:1831761550
Name:GARD, NICOLE MARIE (RDN)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:GARD
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 E MILHAM AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-1490
Mailing Address - Country:US
Mailing Address - Phone:269-888-6805
Mailing Address - Fax:269-280-8990
Practice Address - Street 1:800 E MILHAM AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-1490
Practice Address - Country:US
Practice Address - Phone:269-888-6805
Practice Address - Fax:269-280-8990
Is Sole Proprietor?:No
Enumeration Date:2021-07-13
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI86017402133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered