Healthcare Provider Details

I. General information

NPI: 1770750598
Provider Name (Legal Business Name): AMANDA NICKLES FADER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2008
Last Update Date: 11/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6569 N CHARLES ST SUITE 306
BALTIMORE MD
21204-6831
US

IV. Provider business mailing address

PO BOX 418953
BOSTON MA
02241-8953
US

V. Phone/Fax

Practice location:
  • Phone: 443-849-2765
  • Fax: 443-849-2946
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License NumberMT179962
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License NumberD0069631
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: