Provider Demographics
NPI:1215550439
Name:MAISONVILLE, NICOLE RODDY (OD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:RODDY
Last Name:MAISONVILLE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:NICOLE
Other - Middle Name:LEIGH
Other - Last Name:RODDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:2100 CLINCH AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37916-2293
Mailing Address - Country:US
Mailing Address - Phone:865-521-7998
Mailing Address - Fax:865-521-7405
Practice Address - Street 1:2100 CLINCH AVE STE 400
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37916-2293
Practice Address - Country:US
Practice Address - Phone:865-521-7998
Practice Address - Fax:865-521-7405
Is Sole Proprietor?:No
Enumeration Date:2020-05-21
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3610152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist