Provider Demographics
NPI:1528520558
Name:DORTCH, NIKKI RAE
Entity type:Individual
Prefix:
First Name:NIKKI
Middle Name:RAE
Last Name:DORTCH
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 1:7026 SUMMER HOLLY PL
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33578-4952
Mailing Address - Country:US
Mailing Address - Phone:813-468-5638
Mailing Address - Fax:
Practice Address - Street 1:3030 W DR MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6308
Practice Address - Country:US
Practice Address - Phone:813-872-2929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-31
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9417152163W00000X
FLAPRN11009680363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care
No163W00000XNursing Service ProvidersRegistered Nurse