Provider Demographics
NPI:1679050462
Name:DENNIS, NICOLE K
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:K
Last Name:DENNIS
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 1:820 BESTGATE RD
Mailing Address - Street 2:STE 2A
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-3404
Mailing Address - Country:US
Mailing Address - Phone:410-224-2116
Mailing Address - Fax:410-224-2118
Practice Address - Street 1:9260 CANTERBURY RIDING
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20723-1425
Practice Address - Country:US
Practice Address - Phone:614-579-9340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-24
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR202121207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine