Basic Information
| Provider Information | |||||||||
| NPI: | 1972803955 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICHOLAS | ||||||||
| FirstName: | MAUREEN | ||||||||
| MiddleName: | |||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 51 N 39TH ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191042640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156629189 | ||||||||
| FaxNumber: | 2152434612 | ||||||||
| Practice Location | |||||||||
| Address1: | 51 N 39TH ST | ||||||||
| Address2: | 4 PHI | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191042640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156629189 | ||||||||
| FaxNumber: | 8562167148 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2010 | ||||||||
| LastUpdateDate: | 04/09/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 26NR09306000 | NJ | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 26NJ00332400 | NJ | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | APPLIED | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.