Provider Demographics
NPI:1164224861
Name:BENNING, NICOLE (AGACNP-BC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BENNING
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 SONORA DR
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:MD
Mailing Address - Zip Code:21122-5513
Mailing Address - Country:US
Mailing Address - Phone:240-222-2481
Mailing Address - Fax:
Practice Address - Street 1:2000 MEDICAL PKWY STE 510
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3747
Practice Address - Country:US
Practice Address - Phone:410-897-0822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-25
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR228496363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology