Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 2800 | OH |
NPI | 1669526307 |
---|---|
Provider Name | Nichole Lynn Nygren |
First Address | Van Wert, OH 45891-0027 |
Second Address | Van Wert, OH 45891-1719 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 22/01/2007 |
Last Update Date | 16/10/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000000294842 | ANTHEM (01) | OH |