Provider Demographics
NPI:1477102010
Name:RAEISI, NASIM HOLLY
Entity Type:Individual
Prefix:
First Name:NASIM
Middle Name:HOLLY
Last Name:RAEISI
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 1:204 E JOPPA RD APT 1212
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21286-3136
Mailing Address - Country:US
Mailing Address - Phone:304-685-4975
Mailing Address - Fax:
Practice Address - Street 1:1221 E CHURCHVILLE RD
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014-3411
Practice Address - Country:US
Practice Address - Phone:410-420-8319
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-06
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD26467183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist