Healthcare Provider Details

I. General information

NPI: 1215505367
Provider Name (Legal Business Name): NICOLE VIRGINIA TENNISON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2021
Last Update Date: 06/15/2021
Certification Date: 06/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 MARLBORO RD
LOTHIAN MD
20711-9539
US

IV. Provider business mailing address

1140 MARLBORO RD
LOTHIAN MD
20711-9539
US

V. Phone/Fax

Practice location:
  • Phone: 410-271-5543
  • Fax:
Mailing address:
  • Phone: 410-271-5543
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License NumberA00087423
License Number StateMD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierA00087423
Identifier TypeOTHER
Identifier StateMD
Identifier IssuerBON

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: