Provider Demographics
NPI:1790111383
Name:DUBE, NICOLE PEWITT (APN)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:PEWITT
Last Name:DUBE
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:PEWITT
Other - Last Name:FRYE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3024 BUSINESS PARK CIRCLE
Mailing Address - Street 2:
Mailing Address - City:GOODLETTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37072-3132
Mailing Address - Country:US
Mailing Address - Phone:615-239-2018
Mailing Address - Fax:615-851-2018
Practice Address - Street 1:302 OLD LEBANON DIRT RD STE 200
Practice Address - Street 2:
Practice Address - City:HERMITAGE
Practice Address - State:TN
Practice Address - Zip Code:37076-2391
Practice Address - Country:US
Practice Address - Phone:615-391-4545
Practice Address - Fax:615-391-4546
Is Sole Proprietor?:No
Enumeration Date:2013-09-16
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN000017888363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN6022421OtherBCBS
TNQ009385Medicaid
KY7100348020Medicaid