Provider Demographics
NPI:1548975253
Name:NICEWARNER, STEPHEN (CRNP)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:NICEWARNER
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8205 BLUE HERON DR APT 3D
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21701-9374
Mailing Address - Country:US
Mailing Address - Phone:301-788-1565
Mailing Address - Fax:
Practice Address - Street 1:490 PROSPECT BLVD STE L
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701-6430
Practice Address - Country:US
Practice Address - Phone:240-566-3001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-17
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR228108207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDR228108OtherCRNP LICENSE