Provider Demographics
NPI:1033424932
Name:FOX, NIKKI SHANDELL (DO)
Entity Type:Individual
Prefix:
First Name:NIKKI
Middle Name:SHANDELL
Last Name:FOX
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7235 BOAT CLUB RD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76179-4555
Mailing Address - Country:US
Mailing Address - Phone:817-677-9535
Mailing Address - Fax:817-677-9536
Practice Address - Street 1:7235 BOAT CLUB RD
Practice Address - Street 2:
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76179-4555
Practice Address - Country:US
Practice Address - Phone:817-677-9535
Practice Address - Fax:817-677-9536
Is Sole Proprietor?:No
Enumeration Date:2010-08-16
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010179876208100000X
TXP8131208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP8131OtherTEXAS MEDICAL LICENSE
TX1D4646OtherMEDICARE PTAN