Provider Demographics
NPI:1215505367
Name:TENNISON, NICOLE VIRGINIA
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:VIRGINIA
Last Name:TENNISON
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 1:1140 MARLBORO RD
Mailing Address - Street 2:
Mailing Address - City:LOTHIAN
Mailing Address - State:MD
Mailing Address - Zip Code:20711-9539
Mailing Address - Country:US
Mailing Address - Phone:410-271-5543
Mailing Address - Fax:
Practice Address - Street 1:1140 MARLBORO RD
Practice Address - Street 2:
Practice Address - City:LOTHIAN
Practice Address - State:MD
Practice Address - Zip Code:20711-9539
Practice Address - Country:US
Practice Address - Phone:410-271-5543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-15
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00087423251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDA00087423OtherBON