Healthcare Provider Details

I. General information

NPI: 1174007355
Provider Name (Legal Business Name): KAYLEE BREANNE NICHOLSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KAYLEE BREANNE NICHOLSON RN

II. Dates (important events)

Enumeration Date: 09/24/2018
Last Update Date: 09/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 OKOLONA DR
ERWIN TN
37650-1387
US

IV. Provider business mailing address

101 OKOLONA DR
ERWIN TN
37650-1387
US

V. Phone/Fax

Practice location:
  • Phone: 423-743-9103
  • Fax:
Mailing address:
  • Phone: 423-743-9103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number230562
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: