Provider Demographics
NPI:1407902299
Name:NICHOLS, MARY E (CRNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:NICHOLS
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 1:15005 SHADY GROVE RD STE 450
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-6377
Mailing Address - Country:US
Mailing Address - Phone:301-738-6420
Mailing Address - Fax:301-738-2215
Practice Address - Street 1:15005 SHADY GROVE RD STE 450
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-6377
Practice Address - Country:US
Practice Address - Phone:301-738-6420
Practice Address - Fax:301-738-2215
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR071024363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health