Basic Information
| Provider Information | |||||||||
| NPI: | 1487090114 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REGIS | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KERSHNER | ||||||||
| OtherFirstName: | NICOLE | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | O.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2023 PULASKI HWY | ||||||||
| Address2: | |||||||||
| City: | HAVRE DE GRACE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210782137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109396477 | ||||||||
| FaxNumber: | 4109396555 | ||||||||
| Practice Location | |||||||||
| Address1: | 127 LUBRANO DR STE 301 | ||||||||
| Address2: | |||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 214017560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102242010 | ||||||||
| FaxNumber: | 4102243044 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2013 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | TA2322 | MD | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.