Provider Demographics
NPI:1023834009
Name:DOTSON, NICKI
Entity type:Individual
Prefix:
First Name:NICKI
Middle Name:
Last Name:DOTSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4609 GRAPE RD
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-2649
Mailing Address - Country:US
Mailing Address - Phone:574-220-7885
Mailing Address - Fax:317-967-2229
Practice Address - Street 1:4609 GRAPE RD
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-2649
Practice Address - Country:US
Practice Address - Phone:574-220-7885
Practice Address - Fax:317-967-2229
Is Sole Proprietor?:No
Enumeration Date:2024-11-25
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN24017411374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300095694Medicaid