MEDICARE: MRS. NICOLYN YVONNE NICHOLSON

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	363LF0000X	Family Nurse Practitioner	R112124	MD

General Provider Information

NPI Number	:	1972817278
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. NICOLYN YVONNE NICHOLSON

Provider Business Mailing Address
First Line	:	1701 MCCORMICK DR
Second Line	:
City	:	LARGO
State	:	MD
Zip	:	20774-5329
Country	:	US
Telephone Number	:	301-883-8778
Fax Number	:	301-883-8796

Provider Business Practice Location Address
First Line	:	1701 MCCORMICK DR
Second Line	:
City	:	LARGO
State	:	MD
Zip	:	20774-5329
Country	:	US
Telephone Number	:	301-883-8778
Fax Number	:	301-883-8796

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

Provider Enumeration Date	:	07/29/2010
Last Update Date	:	07/29/2010

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