Provider Demographics
NPI:1073238846
Name:QUEEN, NICOLE (PMHNP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:QUEEN
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3214 E JOPPA RD
Mailing Address - Street 2:
Mailing Address - City:PARKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21234-3307
Mailing Address - Country:US
Mailing Address - Phone:443-703-8345
Mailing Address - Fax:
Practice Address - Street 1:8713 HARFORD RD
Practice Address - Street 2:
Practice Address - City:PARKVILLE
Practice Address - State:MD
Practice Address - Zip Code:21234-4650
Practice Address - Country:US
Practice Address - Phone:443-703-8345
Practice Address - Fax:410-305-6221
Is Sole Proprietor?:No
Enumeration Date:2022-10-05
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR200798363LP0808X, 163WP0807X, 163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health