Provider Demographics
NPI:1700995206
Name:JEFFERSON, NICKOLA SNOW (FNP)
Entity Type:Individual
Prefix:
First Name:NICKOLA
Middle Name:SNOW
Last Name:JEFFERSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10621 CHEVY DR
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37922-3105
Mailing Address - Country:US
Mailing Address - Phone:865-966-1934
Mailing Address - Fax:423-566-5896
Practice Address - Street 1:240 HANNAH RD
Practice Address - Street 2:
Practice Address - City:HARRIMAN
Practice Address - State:TN
Practice Address - Zip Code:37748-5851
Practice Address - Country:US
Practice Address - Phone:865-776-3712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6167207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3905026Medicare PIN