Healthcare Provider Details

I. General information

NPI: 1538884432
Provider Name (Legal Business Name): KEVIN NICKENS FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2022
Last Update Date: 10/04/2022
Certification Date: 09/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 CEDAR LN
KNOXVILLE TN
37912-3507
US

IV. Provider business mailing address

5201 WESTERN AVE APT 515
KNOXVILLE TN
37921-4195
US

V. Phone/Fax

Practice location:
  • Phone: 865-666-3640
  • Fax: 865-666-3641
Mailing address:
  • Phone: 865-232-8017
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number32232
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: