Provider Demographics
NPI:1053920025
Name:BOMAR, NICOLE P (RD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:P
Last Name:BOMAR
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 RICH ST
Mailing Address - Street 2:
Mailing Address - City:SLATER
Mailing Address - State:MO
Mailing Address - Zip Code:65349-1251
Mailing Address - Country:US
Mailing Address - Phone:660-631-3598
Mailing Address - Fax:
Practice Address - Street 1:515 RICH ST
Practice Address - Street 2:
Practice Address - City:SLATER
Practice Address - State:MO
Practice Address - Zip Code:65349-1251
Practice Address - Country:US
Practice Address - Phone:660-631-3598
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-27
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020020010133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered