Basic Information
| Provider Information | |||||||||
| NPI: | 1770843583 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOCKERY | ||||||||
| FirstName: | NIKI | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3889 | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376023889 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237945520 | ||||||||
| FaxNumber: | 4232826940 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 MED TECH PKWY STE 240 | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237945520 | ||||||||
| FaxNumber: | 4232826940 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2012 | ||||||||
| LastUpdateDate: | 03/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 0024171734 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LA2200X | 16709 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 1770843583 | 05 | NC | MEDICAID | 7100211580 | 05 | KY | MEDICAID | 1530448 | 05 | TN | MEDICAID | 1770843583 | 05 | VA | MEDICAID |