Healthcare Provider Details

I. General information

NPI: 1386508638
Provider Name (Legal Business Name): NICOLE C HUMPHREYS CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2025
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2002 MEDICAL PKWY STE 500
ANNAPOLIS MD
21401-3268
US

IV. Provider business mailing address

2002 MEDICAL PKWY STE 500
ANNAPOLIS MD
21401-3268
US

V. Phone/Fax

Practice location:
  • Phone: 410-573-6480
  • Fax:
Mailing address:
  • Phone: 410-573-6480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR169473
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: