Basic Information
| Provider Information | |||||||||
| NPI: | 1184827321 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FARMER | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1910 TOWNE CENTRE BLVD | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 214013675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154070276 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1901 BUTTERFIELD ROAD | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | DOWNERS GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605151279 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6307252737 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2007 | ||||||||
| LastUpdateDate: | 06/12/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MT184746 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | D66778 | MD | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 015749000 | 05 | MD | MEDICAID |