Provider Demographics
NPI:1780008359
Name:PANAS, NICHOLETTE
Entity Type:Individual
Prefix:
First Name:NICHOLETTE
Middle Name:
Last Name:PANAS
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 1:515 BRIGHTFIELD ROAD
Mailing Address - Street 2:
Mailing Address - City:LUTHERVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21093
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:515 BRIGHTFIELD ROAD
Practice Address - Street 2:
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093
Practice Address - Country:US
Practice Address - Phone:410-296-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-18
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA3983225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant