1700196284 NPI number — NICOLE TANNAHILL PT

Table of content: NICOLE TANNAHILL PT (NPI 1700196284)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700196284 NPI number — NICOLE TANNAHILL PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TANNAHILL
Provider First Name:
NICOLE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KETTERER
Provider Other First Name:
NICOLE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1700196284
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/19/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20410 CENTURY BLVD
Provider Second Line Business Mailing Address:
NRH REGIONAL REHAB, SUITE 215
Provider Business Mailing Address City Name:
GERMANTOWN
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20874
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-540-6140
Provider Business Mailing Address Fax Number:
301-540-5190

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
900 EAST 33RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21218
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-540-6140
Provider Business Practice Location Address Fax Number:
301-540-5190
Provider Enumeration Date:
10/18/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  18663 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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