Healthcare Provider Details

I. General information

NPI: 1578467940
Provider Name (Legal Business Name): KASSANDRA NICHOLSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2026
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 BESTGATE RD STE D
ANNAPOLIS MD
21401-3048
US

IV. Provider business mailing address

3850 BOSTON ST APT 3020
BALTIMORE MD
21224-5765
US

V. Phone/Fax

Practice location:
  • Phone: 667-270-7411
  • Fax:
Mailing address:
  • Phone: 315-430-9213
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number056257
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: