Provider Demographics
NPI:1861755928
Name:TUCKER, NICHOLE ELIZABETH (CRNP)
Entity type:Individual
Prefix:MRS
First Name:NICHOLE
Middle Name:ELIZABETH
Last Name:TUCKER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:MS
Other - First Name:NICHOLE
Other - Middle Name:ELIZABETH
Other - Last Name:HOUGHTLING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CPNP
Mailing Address - Street 1:200 FORBES ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-1538
Mailing Address - Country:US
Mailing Address - Phone:410-263-6363
Mailing Address - Fax:410-263-4086
Practice Address - Street 1:200 FORBES ST
Practice Address - Street 2:STE 200
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-1538
Practice Address - Country:US
Practice Address - Phone:410-263-6363
Practice Address - Fax:410-263-4086
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-22
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR191254363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDR191254OtherCRNP RN LICENSE #