Provider Demographics
NPI:1508120908
Name:NUCKOLLS, DAWN M (DO)
Entity Type:Individual
Prefix:DR
First Name:DAWN
Middle Name:M
Last Name:NUCKOLLS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:215 E SPRINGBROOK DR
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-1761
Mailing Address - Country:US
Mailing Address - Phone:423-794-5520
Mailing Address - Fax:423-282-6940
Practice Address - Street 1:301 MED TECH PKWY
Practice Address - Street 2:SUITE 240
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604
Practice Address - Country:US
Practice Address - Phone:423-794-5520
Practice Address - Fax:423-282-0720
Is Sole Proprietor?:No
Enumeration Date:2012-06-29
Last Update Date:2020-05-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TNDO2590207R00000X
VA0116025042207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ013768Medicaid
VA1508120908Medicaid
TN10311I2930Medicare PIN