Basic Information
Provider Information | |||||||||
NPI: | 1790111383 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DUBE | ||||||||
FirstName: | NICOLE | ||||||||
MiddleName: | PEWITT | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | APN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | FRYE | ||||||||
OtherFirstName: | NICOLE | ||||||||
OtherMiddleName: | PEWITT | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3024 BUSINESS PARK CIRCLE | ||||||||
Address2: |   | ||||||||
City: | GOODLETTSVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 370723132 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6158516033 | ||||||||
FaxNumber: | 6158512018 | ||||||||
Practice Location | |||||||||
Address1: | 5651 FRIST BLVD STE 400 | ||||||||
Address2: |   | ||||||||
City: | HERMITAGE | ||||||||
State: | TN | ||||||||
PostalCode: | 370762058 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6153914545 | ||||||||
FaxNumber: | 6153914546 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/16/2013 | ||||||||
LastUpdateDate: | 03/17/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/17/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | APN000017888 | TN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | Q009385 | 05 | TN |   | MEDICAID | 6022421 | 01 | TN | BCBS | OTHER | 7100348020 | 05 | KY |   | MEDICAID |