Healthcare Provider Details

I. General information

NPI: 1861755928
Provider Name (Legal Business Name): NICHOLE ELIZABETH TUCKER CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NICHOLE ELIZABETH HOUGHTLING CPNP

II. Dates (important events)

Enumeration Date: 06/22/2012
Last Update Date: 12/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 FORBES ST STE 200
ANNAPOLIS MD
21401-1538
US

IV. Provider business mailing address

200 FORBES ST SUITE 200
ANNAPOLIS MD
21401-1538
US

V. Phone/Fax

Practice location:
  • Phone: 410-263-6363
  • Fax: 410-263-4086
Mailing address:
  • Phone: 410-263-6363
  • Fax: 410-263-4086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberR191254
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: