Provider Demographics
NPI:1841379781
Name:PELLETIER, NICHOLE LYNN (CRNP)
Entity type:Individual
Prefix:MRS
First Name:NICHOLE
Middle Name:LYNN
Last Name:PELLETIER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:MISS
Other - First Name:NICHOLE
Other - Middle Name:LYNN
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:MD
Mailing Address - Zip Code:20636-0189
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:23415 THREE NOTCH RD
Practice Address - Street 2:SUITE 2054 WILDWOOD CENTER
Practice Address - City:CALIFORNIA
Practice Address - State:MD
Practice Address - Zip Code:20619-4017
Practice Address - Country:US
Practice Address - Phone:301-737-7833
Practice Address - Fax:301-737-4865
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR162889363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD125PM916Medicare PIN