Provider Demographics
NPI:1073997607
Name:SMALL, NICOLE (CRNP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:SMALL
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7831 STONEBRIAR DR STE 200
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21060-8392
Mailing Address - Country:US
Mailing Address - Phone:443-804-3487
Mailing Address - Fax:
Practice Address - Street 1:7831 STONEBRIAR DR
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21060-8392
Practice Address - Country:US
Practice Address - Phone:443-804-3487
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-14
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR226246207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine