Individual
THERESA RENEE NICKOLAUS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
RD, LD, IBCLC
Contact information
Practice address
1011 SCENIC OAKS CT, IMPERIAL, MO 63052-3457
(314) 363-6186
Mailing address
1011 SCENIC OAKS CT, IMPERIAL, MO 63052-3457
(314) 363-6186
Taxonomy
Speciality
Code
Description
License number
State
133V00000X
Registered Dietitian
Primary
2011041352
MO
174N00000X
Lactation Consultant (Non-RN)
L-124884
—
Other
Enumeration date
08/20/2021
Last updated
08/20/2021
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