Provider Demographics
NPI:1568470235
Name:KEARNEY, NICOLE S (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:S
Last Name:KEARNEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 PHYSICIANS DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-2070
Mailing Address - Country:US
Mailing Address - Phone:731-664-9928
Mailing Address - Fax:731-664-9749
Practice Address - Street 1:60 PHYSICIANS DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2070
Practice Address - Country:US
Practice Address - Phone:731-664-9928
Practice Address - Fax:731-664-9749
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN41059208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN195037OtherBETTER HEALTH PLANS OF TN
TN4133891OtherBCBS
TN195037OtherUNISON
TN7347856OtherATHENA
TN38165OtherTLC
TN3827707Medicaid
TN166271Medicare PIN
TN38165OtherTLC