Provider Demographics
NPI:1891239349
Name:PICKLE, IVAN LIONEL JR (LPN)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:LIONEL
Last Name:PICKLE
Suffix:JR
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 N STATE OF FRANKLIN RD
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-6035
Mailing Address - Country:US
Mailing Address - Phone:423-431-1410
Mailing Address - Fax:423-431-6370
Practice Address - Street 1:400 N STATE OF FRANKLIN RD
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6035
Practice Address - Country:US
Practice Address - Phone:423-431-1410
Practice Address - Fax:423-431-6370
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-16
Last Update Date:2016-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN32270164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse