Provider Demographics
NPI:1457813495
Name:DESHAIES, NICOLE ALYSSA (MD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ALYSSA
Last Name:DESHAIES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 FREDERICK HEALTH WAY
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21701-9435
Mailing Address - Country:US
Mailing Address - Phone:240-215-6310
Mailing Address - Fax:
Practice Address - Street 1:7211 BANK CT
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21703-8483
Practice Address - Country:US
Practice Address - Phone:240-215-6310
Practice Address - Fax:240-566-7754
Is Sole Proprietor?:No
Enumeration Date:2019-04-01
Last Update Date:2025-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD484637208600000X
MDD0103565208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
16129183OtherCAQH