Provider Demographics
NPI:1497413587
Name:NICHOLSON, SHAKIA AMANI (NP)
Entity type:Individual
Prefix:
First Name:SHAKIA
Middle Name:AMANI
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 BAGLEY ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23704-6105
Mailing Address - Country:US
Mailing Address - Phone:757-633-8873
Mailing Address - Fax:
Practice Address - Street 1:7501 SURRATTS RD STE 308
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735-3377
Practice Address - Country:US
Practice Address - Phone:301-877-7200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-06
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024182878363L00000X
DCNP20000532363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty