Healthcare Provider Details

I. General information

NPI: 1750921599
Provider Name (Legal Business Name): NICKEISHA WELLINGTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2020
Last Update Date: 08/14/2020
Certification Date: 08/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

726 LINDEN GROVE PL APT 103
ODENTON MD
21113-2785
US

IV. Provider business mailing address

726 LINDEN GROVE PL APT 103
ODENTON MD
21113-2785
US

V. Phone/Fax

Practice location:
  • Phone: 301-658-8658
  • Fax:
Mailing address:
  • Phone: 301-658-8658
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License NumberA00154150
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: