Provider Demographics
NPI:1326098146
Name:WARREN, NICOLE (CNM)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:WARREN
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 64313
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4313
Mailing Address - Country:US
Mailing Address - Phone:410-614-2274
Mailing Address - Fax:
Practice Address - Street 1:525 N WOLFE ST
Practice Address - Street 2:ROOM 448
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21205-2110
Practice Address - Country:US
Practice Address - Phone:410-502-6264
Practice Address - Fax:410-502-5481
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2010-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-005189367A00000X
MDR141805367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD029699600Medicaid
IL209-005189OtherSTATE LICENSE #
MD029699600Medicaid