Healthcare Provider Details

I. General information

NPI: 1558981803
Provider Name (Legal Business Name): NICOLE NADINE SMITH FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE NADINE GOODE/CRYSTAL/GUERRA

II. Dates (important events)

Enumeration Date: 04/16/2020
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1742 EDEN MILL RD
PYLESVILLE MD
21132-1611
US

IV. Provider business mailing address

1742 EDEN MILL RD
PYLESVILLE MD
21132-1611
US

V. Phone/Fax

Practice location:
  • Phone: 443-900-0810
  • Fax:
Mailing address:
  • Phone: 443-900-0810
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR206455
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN9390067
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024180638
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: