Healthcare Provider Details

I. General information

NPI: 1861951345
Provider Name (Legal Business Name): NICOLE NEUKUM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2019
Last Update Date: 07/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14330 JARRETTSVILLE PIKE
PHOENIX MD
21131-1743
US

IV. Provider business mailing address

14330 JARRETTSVILLE PIKE
PHOENIX MD
21131-1743
US

V. Phone/Fax

Practice location:
  • Phone: 410-666-1700
  • Fax: 410-666-7140
Mailing address:
  • Phone: 410-666-1700
  • Fax: 410-666-7140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number19726
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number19726
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: