Provider Demographics
NPI:1730603721
Name:PAHL, NICOLE MARIE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:PAHL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:OEDEWALDT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:169 MADISON AVE STE 11549
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-5101
Mailing Address - Country:US
Mailing Address - Phone:914-919-9200
Mailing Address - Fax:833-913-2393
Practice Address - Street 1:4701 SANGAMORE RD
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20816-2508
Practice Address - Country:US
Practice Address - Phone:913-919-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-01
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11002516363LW0102X, 367A00000X, 363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103130800Medicaid
FLLF591OtherMEDICARE