Provider Demographics
NPI:1124391883
Name:DAVIS, NICOLE PRINCE (PA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:PRINCE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20010 CENTURY BOULEVARD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20874
Mailing Address - Country:US
Mailing Address - Phone:240-686-2300
Mailing Address - Fax:240-686-2330
Practice Address - Street 1:18101 PRINCE PHILIP DRIVE
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:MD
Practice Address - Zip Code:20832
Practice Address - Country:US
Practice Address - Phone:301-774-8900
Practice Address - Fax:301-570-8571
Is Sole Proprietor?:No
Enumeration Date:2012-02-10
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDC0004676363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical