Healthcare Provider Details

I. General information

NPI: 1063239366
Provider Name (Legal Business Name): KIRA NICKOLS FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2024
Last Update Date: 11/26/2025
Certification Date: 11/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 SAINT PAUL ST
BALTIMORE MD
21202-2123
US

IV. Provider business mailing address

15 BLONDELL CT
TIMONIUM MD
21093-2003
US

V. Phone/Fax

Practice location:
  • Phone: 410-332-9000
  • Fax:
Mailing address:
  • Phone: 443-629-6031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR192096
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: