Healthcare Provider Details

I. General information

NPI: 1689054165
Provider Name (Legal Business Name): JILIAN NICHOLAS D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2015
Last Update Date: 05/03/2022
Certification Date: 05/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 MEDICAL PKWY STE 600
ANNAPOLIS MD
21401-3748
US

IV. Provider business mailing address

PO BOX 412752 APT G8
BOSTON MA
02241-8800
US

V. Phone/Fax

Practice location:
  • Phone: 443-924-2900
  • Fax:
Mailing address:
  • Phone: 443-481-3356
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberH91741
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: