MEDICARE: SHAKIA AMANI NICHOLSON NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	0024182878	VA
2	363L00000X	Nurse Practitioner	NP20000532	DC

General Provider Information

NPI Number	:	1497413587
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHAKIA AMANI NICHOLSON NP

Provider Business Mailing Address
First Line	:	22 BAGLEY ST
Second Line	:
City	:	PORTSMOUTH
State	:	VA
Zip	:	23704-6105
Country	:	US
Telephone Number	:	757-633-8873
Fax Number	:

Provider Business Practice Location Address
First Line	:	7501 SURRATTS RD STE 308
Second Line	:
City	:	CLINTON
State	:	MD
Zip	:	20735-3377
Country	:	US
Telephone Number	:	301-877-7200
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/06/2021
Last Update Date	:	06/17/2024

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