Healthcare Provider Details

I. General information

NPI: 1457199200
Provider Name (Legal Business Name): KEYSHLA MARIE CHACON NIEVES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2024
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 W COLUMBIA ST
EVANSVILLE IN
47710-1656
US

IV. Provider business mailing address

415 W COLUMBIA ST
EVANSVILLE IN
47710-1656
US

V. Phone/Fax

Practice location:
  • Phone: 812-450-3363
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11025008A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: