Provider Demographics
NPI:1508923970
Name:NICHOLSON, STACY LOUISE (DC)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:LOUISE
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9500 PAINTED TREE DR
Mailing Address - Street 2:
Mailing Address - City:RANDALLSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21133-2845
Mailing Address - Country:US
Mailing Address - Phone:410-312-5454
Mailing Address - Fax:
Practice Address - Street 1:10015 OLD COLUMBIA RD
Practice Address - Street 2:SUITE B215
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046-1703
Practice Address - Country:US
Practice Address - Phone:410-312-5454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01749111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD892871Medicare ID - Type Unspecified
MDU64538Medicare UPIN