Healthcare Provider Details

I. General information

NPI: 1396444568
Provider Name (Legal Business Name): MORGAN NICOLE SOUTHERN MSN-FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2023
Last Update Date: 02/27/2023
Certification Date: 02/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 GRANT ST
GARY IN
46402-6001
US

IV. Provider business mailing address

600 HOMELAND RD
MATTESON IL
60443-1781
US

V. Phone/Fax

Practice location:
  • Phone: 219-886-4000
  • Fax:
Mailing address:
  • Phone: 708-509-8381
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209024178
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71013634A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: