Provider Demographics
NPI:1477685311
Name:BEAVERS, NICOLE S (CPNP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:S
Last Name:BEAVERS
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:SELF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 15004
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37901-5004
Mailing Address - Country:US
Mailing Address - Phone:865-541-8895
Mailing Address - Fax:865-633-4808
Practice Address - Street 1:2130 N. CHARLES SEIVERS BLVD
Practice Address - Street 2:SUITE 4
Practice Address - City:CLINTON
Practice Address - State:TN
Practice Address - Zip Code:37716-6705
Practice Address - Country:US
Practice Address - Phone:865-457-4044
Practice Address - Fax:866-699-4833
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6963363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ002695Medicaid