Healthcare Provider Details

I. General information

NPI: 1740541291
Provider Name (Legal Business Name): NICOLE SUZANNE FANNING M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2012
Last Update Date: 08/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9000 FRANKLIN SQUARE DR
BALTIMORE MD
21237
US

IV. Provider business mailing address

9000 FRANKLIN SQUARE DR
BALTIMORE MD
21237-3901
US

V. Phone/Fax

Practice location:
  • Phone: 443-777-8005
  • Fax:
Mailing address:
  • Phone: 443-777-8005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number0101256369
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateVA
# 4
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberD0084730
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: