Nicole Kristina Derse, CNC

Primary specialty

NutritionistTaxonomy code 133N00000X

License

12D577516 Issued in WI

Practice address

308 E Glendale Ave
Appleton, WI 54911-2907

Phone

(920) 322-5115

NPI assigned

Oct 18, 2018

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other names 1

• Nicole James Professional name

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1539820800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1539820800000",
    "number": "1073089934",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "308 E GLENDALE AVE",
            "city": "APPLETON",
            "state": "WI",
            "postal_code": "549112907",
            "telephone_number": "920-322-5115"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "308 E GLENDALE AVE",
            "city": "APPLETON",
            "state": "WI",
            "postal_code": "549112907",
            "telephone_number": "920-322-5115"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "DERSE",
        "first_name": "NICOLE",
        "middle_name": "KRISTINA",
        "name_prefix": "Ms.",
        "credential": "CNC",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2018-10-18",
        "last_updated": "2018-10-18",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "133N00000X",
            "taxonomy_group": "",
            "desc": "Nutritionist",
            "state": "WI",
            "license": "12D577516",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "NICOLE",
            "last_name": "JAMES",
            "credential": "CFMP",
            "code": "2",
            "type": "Professional Name"
        }
    ]
}

• Dana M Derenne, RD
• Nicholas Derkowski
• Dirk Jon Derksen, MD
• Todd Alan Derksen, DPM
• Stephen R Dernlan, MD
• Joy Lucille Des Jardins, COTA
• Katie Jean Des Jardins
• Robert Leo Desjardin, PA
• Craig Daniel Destree
• Joslyn Destree

• All providers in Appleton, WI
• Nutritionist in Wisconsin

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 18, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.