Provider Demographics
NPI:1871676866
Name:KAMMEYER, NICOLE J (OD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:J
Last Name:KAMMEYER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 MAIN ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DAYTON
Mailing Address - State:TN
Mailing Address - Zip Code:37321-1329
Mailing Address - Country:US
Mailing Address - Phone:423-775-4747
Mailing Address - Fax:423-775-4749
Practice Address - Street 1:225 MAIN ST
Practice Address - Street 2:SUITE 200
Practice Address - City:DAYTON
Practice Address - State:TN
Practice Address - Zip Code:37321-1329
Practice Address - Country:US
Practice Address - Phone:423-775-4747
Practice Address - Fax:423-775-4749
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNODT2622152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3946680Medicaid
TN3946680Medicare ID - Type Unspecified
TNV06965Medicare UPIN