Provider Demographics
NPI:1144659400
Name:NICHOLSON, TERRI SHENELL
Entity type:Individual
Prefix:MS
First Name:TERRI
Middle Name:SHENELL
Last Name:NICHOLSON
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 FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21286-5466
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:405 N PACA ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1815
Practice Address - Country:US
Practice Address - Phone:410-779-9609
Practice Address - Fax:443-552-4758
Is Sole Proprietor?:No
Enumeration Date:2013-11-07
Last Update Date:2017-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR164093363LA2100X, 363LF0000X, 363LG0600X, 363LP2300X, 363LS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LS0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerSchool