Provider Demographics
NPI:1134658230
Name:ROBERTS, NICOLE ELAINE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ELAINE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3588 WORKMAN RD STE 101
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37921-5932
Mailing Address - Country:US
Mailing Address - Phone:865-558-8733
Mailing Address - Fax:
Practice Address - Street 1:3588 WORKMAN RD SUITE 101
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37921
Practice Address - Country:US
Practice Address - Phone:865-558-8733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000012141183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0000012141OtherTN PHARMACIST LICENSE