Provider Demographics
NPI:1457840209
Name:KEITH, NICOLE LYN
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYN
Last Name:KEITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 WASHINGTON RD STE F
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:MD
Mailing Address - Zip Code:21157-5838
Mailing Address - Country:US
Mailing Address - Phone:410-871-2990
Mailing Address - Fax:443-293-8703
Practice Address - Street 1:904 WASHINGTON RD STE F
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:MD
Practice Address - Zip Code:21157-5838
Practice Address - Country:US
Practice Address - Phone:410-871-2990
Practice Address - Fax:443-293-8703
Is Sole Proprietor?:No
Enumeration Date:2018-05-08
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD07679225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist