Healthcare Provider Details

I. General information

NPI: 1831245786
Provider Name (Legal Business Name): TERESANN NICKLE FNP-BC, PMHNP-BC, DN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 03/16/2022
Certification Date: 03/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4723 W. MAIN ST. STE H
GUADALUPE CA
93434
US

IV. Provider business mailing address

5831 S HARBISON AVE
INDIANAPOLIS IN
46239-9658
US

V. Phone/Fax

Practice location:
  • Phone: 805-343-5577
  • Fax: 805-249-0091
Mailing address:
  • Phone: 505-506-4700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN501703
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number501703
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number501703
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number71012379A
License Number StateIN
# 5
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN501703
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: