Provider Demographics
NPI:1053568717
Name:TOLLIVER, NIKKI COOK (OTA)
Entity type:Individual
Prefix:
First Name:NIKKI
Middle Name:COOK
Last Name:TOLLIVER
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 802
Mailing Address - Street 2:
Mailing Address - City:NEW TAZEWELL
Mailing Address - State:TN
Mailing Address - Zip Code:37824-0802
Mailing Address - Country:US
Mailing Address - Phone:865-585-1575
Mailing Address - Fax:
Practice Address - Street 1:3300 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37917-2733
Practice Address - Country:US
Practice Address - Phone:865-689-2052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-25
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOTA111224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant