Healthcare Provider Details

I. General information

NPI: 1386584647
Provider Name (Legal Business Name): MS. NICOLE ELLIOTT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2026
Last Update Date: 03/30/2026
Certification Date: 03/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 W REDWOOD ST FL 5
BALTIMORE MD
21201-7008
US

IV. Provider business mailing address

PO BOX 64765
BALTIMORE MD
21264-4765
US

V. Phone/Fax

Practice location:
  • Phone: 410-528-5710
  • Fax:
Mailing address:
  • Phone: 410-528-5710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA12345678
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: