Provider Demographics
NPI:1124594965
Name:COLLICK, NICOLE L
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:L
Last Name:COLLICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 123
Mailing Address - Street 2:
Mailing Address - City:SNOW HILL
Mailing Address - State:MD
Mailing Address - Zip Code:21863-0123
Mailing Address - Country:US
Mailing Address - Phone:443-373-8200
Mailing Address - Fax:
Practice Address - Street 1:201 S ROSS ST
Practice Address - Street 2:
Practice Address - City:SNOW HILL
Practice Address - State:MD
Practice Address - Zip Code:21863-1150
Practice Address - Country:US
Practice Address - Phone:443-373-8200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-19
Last Update Date:2018-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
No174200000XOther Service ProvidersMealsGroup - Single Specialty
No385H00000XRespite Care FacilityRespite CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
YOtherSOLE PROPIETOR CODE