Provider Demographics
NPI:1437377488
Name:NICHOLSON, DEETTE KAY (CNM)
Entity Type:Individual
Prefix:MRS
First Name:DEETTE
Middle Name:KAY
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:MISS
Other - First Name:DEETTE
Other - Middle Name:KAY
Other - Last Name:JUNKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:805 QUAIL RIDGE COURT
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTON
Mailing Address - State:TN
Mailing Address - Zip Code:37643
Mailing Address - Country:US
Mailing Address - Phone:423-543-1681
Mailing Address - Fax:423-543-1681
Practice Address - Street 1:805 QUAIL RIDGE COURT
Practice Address - Street 2:
Practice Address - City:ELIZABETHTON
Practice Address - State:TN
Practice Address - Zip Code:37643
Practice Address - Country:US
Practice Address - Phone:423-543-1681
Practice Address - Fax:423-543-1681
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000012088176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
128CVOtherNORTH CAROLINA BC BS PROV
3116374OtherTENNESSEE BC BS PROVIDER