Provider Demographics
NPI:1871053736
Name:NICHOLSON, REBECCA GOLDSTON (FNP-BC)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:GOLDSTON
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:LYNN
Other - Last Name:GOLDSTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6350 W ANDREW JOHNSON HWY
Mailing Address - Street 2:
Mailing Address - City:TALBOTT
Mailing Address - State:TN
Mailing Address - Zip Code:37877-8605
Mailing Address - Country:US
Mailing Address - Phone:800-355-3565
Mailing Address - Fax:423-714-2355
Practice Address - Street 1:9320 PARK WEST BLVD
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-4301
Practice Address - Country:US
Practice Address - Phone:865-373-7100
Practice Address - Fax:865-374-2029
Is Sole Proprietor?:No
Enumeration Date:2019-03-25
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN89734163W00000X
TNAPN24829363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ048548Medicaid