Healthcare Provider Details

I. General information

NPI: 1619898228
Provider Name (Legal Business Name): NICOLE EVONNE KIESER PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2026
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1004 W 1ST ST
BLOOMINGTON IN
47403-2208
US

IV. Provider business mailing address

8747 N COUNTY ROAD 600 E
SEYMOUR IN
47274-9796
US

V. Phone/Fax

Practice location:
  • Phone: 812-393-5476
  • Fax:
Mailing address:
  • Phone: 812-498-0553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number28144279A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: