Healthcare Provider Details

I. General information

NPI: 1487678835
Provider Name (Legal Business Name): NIKKALYNN F DELAURENTIS DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 12/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1960 MADISON ST STE J #296
CLARKSVILLE TN
37043-8039
US

IV. Provider business mailing address

1960 MADISON ST STE J #296
CLARKSVILLE TN
37043-8039
US

V. Phone/Fax

Practice location:
  • Phone: 219-218-9229
  • Fax: 888-261-6219
Mailing address:
  • Phone: 219-218-9229
  • Fax: 888-261-6219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number2144
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: