Provider Demographics
NPI:1053602763
Name:CONKLING, NICOLE (CRNP)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:
Last Name:CONKLING
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:DIONE
Other - Last Name:GOVIGNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:508 WHITHORN CT
Mailing Address - Street 2:
Mailing Address - City:LUTHERVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21093-7026
Mailing Address - Country:US
Mailing Address - Phone:410-746-8342
Mailing Address - Fax:
Practice Address - Street 1:1407 YORK RD
Practice Address - Street 2:
Practice Address - City:TIMONIUM
Practice Address - State:MD
Practice Address - Zip Code:21093
Practice Address - Country:US
Practice Address - Phone:410-746-8342
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-28
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR172502363LA2200X, 363LG0600X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology