Provider Demographics
NPI:1487678835
Name:DELAURENTIS, NIKKALYNN F (DO)
Entity Type:Individual
Prefix:DR
First Name:NIKKALYNN
Middle Name:F
Last Name:DELAURENTIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1960 MADISON ST STE J
Mailing Address - Street 2:#296
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-8039
Mailing Address - Country:US
Mailing Address - Phone:219-218-9229
Mailing Address - Fax:888-261-6219
Practice Address - Street 1:1960 MADISON ST STE J
Practice Address - Street 2:#296
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-8039
Practice Address - Country:US
Practice Address - Phone:219-218-9229
Practice Address - Fax:888-261-6219
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2144207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHI46331Medicare UPIN
OHDE7338871Medicare ID - Type Unspecified
OH2596696Medicaid