Provider Demographics
NPI:1487090114
Name:REGIS, NICOLE A (OD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:A
Last Name:REGIS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:A
Other - Last Name:KERSHNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:2023 PULASKI HWY
Mailing Address - Street 2:
Mailing Address - City:HAVRE DE GRACE
Mailing Address - State:MD
Mailing Address - Zip Code:21078-2137
Mailing Address - Country:US
Mailing Address - Phone:410-939-6477
Mailing Address - Fax:410-939-6555
Practice Address - Street 1:127 LUBRANO DR STE 301
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-7560
Practice Address - Country:US
Practice Address - Phone:410-224-2010
Practice Address - Fax:410-224-3044
Is Sole Proprietor?:No
Enumeration Date:2013-05-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA2322152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist