Provider Demographics
NPI:1861784118
Name:LEISTIKOW, NICOLE (MD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:LEISTIKOW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1307 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21217-4104
Mailing Address - Country:US
Mailing Address - Phone:443-459-1840
Mailing Address - Fax:
Practice Address - Street 1:1501 SULGRAVE AVE STE 202
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21209-3650
Practice Address - Country:US
Practice Address - Phone:443-459-1840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-04
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MDD788322084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program