Provider Demographics
NPI:1548914005
Name:NUGENT-GYESIE, NICOLE (CRNP PMHNP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:NUGENT-GYESIE
Suffix:
Gender:F
Credentials:CRNP PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4229 YORK RD STE 201
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21212-4884
Mailing Address - Country:US
Mailing Address - Phone:443-345-9645
Mailing Address - Fax:
Practice Address - Street 1:2439 E LAFAYETTE AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21213-2562
Practice Address - Country:US
Practice Address - Phone:443-858-4107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-03
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR203916363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health