Basic Information
| Provider Information | |||||||||
| NPI: | 1790849081 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NICKLE | ||||||||
| FirstName: | KENNETH | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1225 E WEISGARBER RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379092604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655844747 | ||||||||
| FaxNumber: | 8655841363 | ||||||||
| Practice Location | |||||||||
| Address1: | 555 JUSTIS DR | ||||||||
| Address2: | |||||||||
| City: | GREENEVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377454288 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237837965 | ||||||||
| FaxNumber: | 4237837970 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2006 | ||||||||
| LastUpdateDate: | 04/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2153 | TN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.