MEDICARE: MS. ANGELA NICOLE NICKLAS MS CCC-SLP

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	235Z00000X	Speech-Language Pathologist	05065	MD

General Provider Information

NPI Number	:	1568934388
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ANGELA NICOLE NICKLAS MS CCC-SLP

Provider Business Mailing Address
First Line	:	902 9TH ST
Second Line	:
City	:	PASADENA
State	:	MD
Zip	:	21122-1804
Country	:	US
Telephone Number	:	443-386-0972
Fax Number	:

Provider Business Practice Location Address
First Line	:	2900 MACARTHUR RD
Second Line	:
City	:	FORT MEADE
State	:	MD
Zip	:	20755-2123
Country	:	US
Telephone Number	:	410-222-6504
Fax Number	:

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

Provider Enumeration Date	:	12/18/2018
Last Update Date	:	12/18/2018

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